The Use Of Electronic Medical Records In Professional Nursing

Steele, A. M., & DeBrow, M. (2008). Efficiency gains with computerized provider order entry. In: Henriksen K, Battles JB, Keyes MA, Grady ML (eds) Advances in patient safety: new directions and alternative approaches AHRQ publication no 08–0034-4, vol 4. Technology and Medication Safety Agency for Healthcare Research and Quality, Rockville, MD. Retrieved from http://www.ahrq.gov/qual/advances2/

* Reduction of medication errors- Barcode medication administration safeguards against wrong pt/wrong med/wrong dose errors and alerts to potential medication interactions (Goth, 2006).

Besides the disadvantages of (EMR)’s the advantages pose great benefits to patient care and efficiency. The greater use of electronic medical records or health records can reduce wait times, of seeing doctors or waiting for test results. All staff would need to cohesively work out the technical challenges and software data. With sophisticated IT

“The United States based Institute of Medicine (IOM) reported in 1999 that at least 44,000 people, and perhaps as many as 98,000 people, die in hospitals each year as a result of medical errors that could have been prevented…” (Anonymous, 2015). When faced with more than a singular sentinel event related to medication administration errors, the organization must begin to look into why this happened and what can be done to prevent any more errors from occurring. Implementing new bar code technology into a new electronic health record (EHR) system can dramatically reduce the number of errors made by healthcare providers. In order to implement a new system; several steps must occur. An informatics nurse plays a vital role in not only the design of new program interfaces, but in developing educational programs for the new systems. Not all studies have shown that implementing a new bar coding system can be beneficial to healthcare providers, though.

I was a nursing assistant for a community hospital that had been purchased into a much larger, and successful health system. One year prior to me leaving the organization, the electronic medical record system was being implemented from 50% paper (which included: discharge instructions, admission and provider notes) to 100% electronic. The process, I believe, was strong however, it could have been improved. To my knowledge, and one of the improvements that could have been made was sharing the goals and strategy for why we were going in this route. Another improvement that could have been made was including us in the process for more buy in. I do understand why this may not have been the best option because this was a hospital-wide initiative.

These systems will also help cut down on medication errors by comparing the patient’s to medications or interventions so that it is given to the correct patient. Also documents the care given so there would be no human error in the case of questioning whether care had been given as long as the caregiver documents in the record. These features of the electronic health record are in place to promote patient safety by reducing errors.

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to

Bar-coded medication administration (BCMA) systems are also commonly used by nurses to improve medication administration in inpatient settings. As an illustration, a study in 2007 showed that BCMA systems reduced medication administration errors by 54-87% in hospitals in the US. It has been reported that a large number of medication errors happens at care transition points, i.e., during admission, transfer and discharge of patients. Thus, medication reconciliation at all transition points could significantly improve medication safety. In fact, preliminary evidences suggest that application of electronic medication reconciliation systems are quite effective in reducing such errors. Additionally, electronic personal health record (EHR) systems can be used to reduce medication errors. These IT systems allow patients to access, coordinate their health information and make it available to their healthcare providers. IT systems are also used to reduce medication errors of omission. As an example, recent studies have demonstrated that smart electronic discharge systems utilized in some hospitals can alert physicians to prescribe important medications.

This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the

An Electronic Health Record is a computerized form of a patient’s medical chart. These records allow information to be readily available to authorized providers during a patient’s encounter with the healthcare system. These systems do not only contain medical histories, current medications and insurance information, they also track patients’ diagnoses, treatment plans, immunization dates, allergies, radiology images and lab tests/results (source). The fundamental aspect of EHRs is that they are able to share a patient’s information quickly across service lines and even between different healthcare organizations. Information is at the fingertips of lab techs, primary care physicians, pharmacies, clinics, etc. The

Instead of using paper based records, technology allows physicians to use the electronic medical record (EMR) that improves the quality of programs. By using the EMR, this is not easy nor is it low cost. Physicians’ have to use this method as their daily task. There are some barriers that has been identified with the use of the EMR by the physicians we will discuss. There will be some suggestions made that might can help the policy interventions to overcome the barriers. This will include the support system of work/practice including electronic clinical data exchange, and financial rewards for quality improvement. (Sim, 2004)

In the healthcare segment as well as general public there is a huge confusion regarding understanding electronic health records (EHR) and electronic medical records (EMR), as both are digital record keeping techniques. However, EMR and EHR are both different in a way that one is a transition between paper and electronic records, while the other is an advanced healthcare system. Understanding this difference helps them leverage the techniques effectively for an added advantage.

Electronic medical records (EMR) software is a rapidly changing and often misunderstood technology with the potential to cause great change within the medical field. Unfortunately, many healthcare providers fail to understand the complex functions of EMRs, and they rather choose to use them as a mere alternative to paper records. EMRs, however, have many functionalities and uses that could help to improve the patient-physician relationship and the overall quality of patient care. In order for this potential to be realized, both the patient and the healthcare provider must have a deeper understanding of EMR purpose and function. In this paper will highlights the historical developments and its potential effects on the patient physician relationship in order to

Electronic medical records had a great impact in the ushering in of the age of Nursing Informatics. (Himss, 2010)EMRS present healthcare professionals with the ability to retrieve and organize data in a quick and efficient approach. With information so readily available, patient safety increases and we know that patient cost goes down. This happens because patient medications, allergies, history, demographic, and treatment information is more collectively available.

The creation of technology changed the way healthcare is being received, and even organized. The introduction of electronic medical records, to finding cures that humans thought would not be possible, healthcare has changed right in front of everyone’s eyes. Let’s discuss what exactly a computer is and how technology is changing in the field of healthcare and medicine.