Deficiencies in nursing recording have forced the stakeholders to implement interventions aimed at improving healthcare documentation. Healthcare providers need to determine the best approaches for incorporating the elements of nursing into Electronic Health Records. Electronic documentation ensures long-term preservation and storage of records, which promotes evidence-based nursing care (Busch, 2008). Capturing nursing’s independent contributions to patient care requires proper comprehension and application of standardized terminologies that reflect the uniqueness of the healthcare systems. Correct use of standardized terminologies benefits the nursing profession through enhancing communication among the nursing stakeholders, increasing visibility of nursing interventions and facilitating assessment of nursing competency. The Focus of Documentation of Patient Care Information recording is a critical part of medical endeavor. Busch (2008) maintains that medical care requires continuous flow of information before and after each task to maintain continuity of care. The tasks in the medical care are interdependent and build on one another to achieve the goals of nursing practice. Nurses have the responsibility of managing and implementing the plans of the medical team for the patient through recording the progress towards the outcomes. Nurses collect the patient’s information during diagnosis and record the same in files kept in the hospitals. The objective of collecting this information is to enable the nurses to trace the medical history of the patients during diagnosis in order to help them identify genealogical and chronic diseases. Future nurses for patients will also need this data for understanding the earlier medicine and its effects on the patient over time. Lack of documentation may lead to lose of crucial information required by both the nursing organization and the patients (Azari, Janeja & Mohseni, 2012). Practicing nurses, therefore, need to be educated to the necessity of documenting care using standardized nursing languages in this era when sectors are rapidly embracing electronic documentation. Documentation in healthcare focuses on enhancing communication and continuity of care among the nurses and other healthcare professionals involved in the profession. Communication between the nurses and the nurses and among doctors cannot be possible, unless there is proper documentation. Doctors do not meet physically to discuss the progress of patients in most cases; documents are sent from one section of the hospital to another for the intended provider to act appropriately (Busch, 2008). Proper documentation stimulates the process of communication in the hospital, which ensures that the healthcare stakeholders achieve their objectives. Another focus of medical documentation is ensuring evidence for future reference. There are cases where doctors give incorrect medication to patients. These patients may develop complications, which may lead to legal liabilities. The courts of law require the records to serve as evidence for incorrect treatment disseminated. Documentation ensures that these records are available whenever required. Additionally, proper documentation leads to recording of data that is crucial for research and education (Ripley, 2009). Practicing students of medicine and nursing can refer to these documents when there is a need to link theoretical knowledge to practical knowledge. Documentation,
Nursing Documentation in the Age of the Electronic Health Record Name Institution Nursing Documentation in the Age of the Electronic Health Record Introduction Health care providers and administrators view record keeping as a critical element that promotes safety, quality, compliance and continuity of service…
This paper has covered the basic application or EHRs, its uses in medical and healthcare sector, process of transformation of manual information to digital details and finally assessment of how we can attain meaningful information to such records. This paper has also discusses several advantages and disadvantages of this modern technology.
The researcher of this essay aims to pay special attention to converting paper records to electronic records and establishing ‘meaningful use’. The process of shifting from paper records to electronic health records should be carefully planned and implemented. The paper will also evaluate and present advantages and disadvantages of EHRs.
This is because lack of complete commitment, lack of alertness or lack of balance while treating a patient can lead to occurrence of errors which can prove fatal and injurious to the lives and health of patients. Hence, it is extremely important for people in the profession of nursing to remain alert, updated and balanced in their professional life.
It is claimed that electronic health record implants (EHRi) “provides the opportunity for healthcare organizations to improve the quality of care and patient safety”. Therefore, implementation of this technology in any health institution needs to be approached with utmost care, precaution, and careful thought.
These systems can also be found in various hospitals. They are usually standalone systems that have all the records of patients that come to a particular doctor for treatment. No one other than a person who uses the system or has access to the data can store new data or edit the existing one in an electronic health record system.
Electronic Documentation in Health Sector Literature Review There is the need in the modern day practice to embrace information technology and advanced nursing practices in order to realize the current as well as future nursing needs within the society. Health care record keeping by electronic means is a basic tool to be exploited to address the rising complexities within the nursing field.
Moreover, it is usually associated with myriad and complicated challenges that require proper decision making beginning by the process of selection, implementation as well as training and maintaining the electronic health records. This
The results show that the EHRs have great benefits such as improved quality and convenience of patient care, Improved Patient participation and Improved Diagnostics and patient outcomes. The research indicates 94 % of providers reporting improved availability