Application of EHR on inpatient nursing Introduction Organizational efficiency is one of the major beneficiaries of technological developments. Advancements in information technology have for example been used in monitoring and evaluation of operations besides facilitating communication…
This paper seeks to discuss application of electronic health record system in inpatient nursing. The paper will explore application of the technology in inpatient nursing’s assessment, medication, and documentation. It will also explore successful implementation of the electronic health record system and its importance in the scope of inpatient nursing. Application of electronic health record in documentation The core function of electronic health record is the development of a reliable information system for efficiency. This has led to transition, alongside technological developments, from a manual record keeping system to the electronic system through computer technology. The information system has further enhanced the health record system through networking involved instruments, departments, and personnel in the electronics record systems. Documentation is, as a result, one of the applications of electronic health record system through a variety of system applications that includes provision of information in facilities such as inpatient nursing facilities. The scope of documentation, based on its definition, includes recording of information and availing the recorded information for necessary use. The “nursing information system,” an incorporated system in inpatient nursing institutions is for example used in documenting information for administrative purposes (Carter, 2008, p. 4). The system manages all information relating to inpatients such as patient’s admission that provides relevant details of a patient to the hospitals system (Carter, 2008). Guite et al further explains that electronic health record is used to capture and communicate a patient’s details for determination of patients’ needs and evaluation of the patients’ utility while in the nursing facilities. Coordination also facilitates knowledge of patients’ needs among personnel on duty (n.d.). Documentation in electronic health record is also used to facilitate management of information for timely discharge of patients and even transfer of patients to other facilities for specialized attention. Like in admission, documentation, through a centralized operated system facilitates inter departmental communication to relay the need for either discharge or transfer. Similarly, documentation as an element of electronic health record facilitates accounting aspects of health care institutions, a role that is achieved through recording and organization of financial transactions and communication of the information to managers for administration (Carter, 2008). Inpatient nursing facilities also use electronic health record’s documentation to facilitate direct personal communication among nurses through online chats for instant communication. The application of electronic health record in documentation is therefore based on its ability to develop a bank of necessary and relevant information to inpatient care and to communicate such information to relevant departments and personnel for efficient operations and management. Standardized terms and systems for uniformity in documentation facilitate the efficiency by eliminating language based communication barrier (Carter, 2008). Application of electronic health record in nursing’s documentation is however subject to legal considerations that aim at preventing malpractices such as fraud. Such rules apply to both EHR technology developers and users in inpatient nurs ...
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It is also evident that with the effective advent of the requirement of meaningful use by the US government, the implementation and adoption of the EHR are compulsory and mandatory. Thus, the roadmap that was government-mandated for the EHR elaborately signifies serious implications to the definition and success critical factors of the EHR implementation.
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