Electronic Charting Of The Emergency Room

The issue of documentation of patient care has received considerable attention in the last few years for an array of reasons. Trends in society such as increased consumer education, informed consent, expectation for healthy baby, and an increasingly litigious society all contribute to increased risk management awareness on behalf of healthcare facilities. Risk management deals with the probability that a given risk will result in poor outcome and then attempts to reduce probability. El Centro Regional Medical Center (ECRMC) has identified nursing documentation as an area of greatest risk

Although EMR’s may be taking over the medical world, paper medical charts remain the most well recognized form for keeping medical records. There are however some things within paper charts that some medical personnel might argue make it a primitive aspect of the medical field. One argument in itself is that the abundance of paper that is utilized in paper charting doesn’t stand up to the “green” society we aspire to live in today. “Paper charting used to take so long, the papers would always get unorganized, they took up so much room in the nurses’ station and the worst was waiting for a doctor to finish with a chart so I could chart what I needed to” (Brittney Guggino LPN, 2012). Another acknowledged concern with paper medical charts is the illegible handwriting of clinicians, which is a common, longstanding problem. Being unable to read orders clearly creates an added risk when dealing with patients treatments, medications etc. Paper charts may be familiar but they come with many downfalls and it’s these downfalls which may sway a person’s decision in the opposite direction in regards to the

S (situation): Hi, my name Kelsey and I am a nurse in the emergency department. I am calling about Shannon O’Reilly’s most recent laboratory results.

Healthcare is a complex industry that is consistently changing to meet the demand of improving quality patient care. As a member of the healthcare team, we are obligated to provide safe patient-centered care. However, patient care within the facility this nurse is employed is not as effective as it should be. The organization currently utilizes three different charting systems, two electronic health information systems and a paper chart. Each with its own purpose of use. To make matters worse, not all healthcare providers have access to both electronic health information system. Depending on the individuals professional role within the organization, access would be limited to one or the other. Nurses are the only one

“Handwriting has always been, and will remain, a problem in medicine. A 1979 study showed that it was difficult to interpret about half of all physicians' handwritten orders. Little has changed since then,” (In the long run, penmanship classes for doctors won't do much for patient safety, 2001). This has been an ongoing problem since inception. Therefore, the beginning of the process should be changed in this day and age of technology to have prescriptions entered into computers and handheld devices by the doctor, to ensure accuracy of the medication that is needed to be filled, and electronically sent to the pharmacy. Having a nurse call in prescriptions is a non-value added activity that can be eliminated. This may be expensive at the start to implement, but in the long term, it will save both organizations time, help reduce errors, and add value to the level of service the organization gives. With this change, label errors should also be reduced as well, ensuring the patient receives the correct medicine and dosage.

This has lead to orders not being enter correctly or being missed all together. Resulting in inadequate patient care that can be prevented should the providers have access to the system and enter orders themselves. Keller (2016) wrote that verbal orders can often be misconstrue and enter incorrectly due to multiple distractions. Further legibility is a frequent issue with written orders. As with verbal orders, illegible written orders can lead to medical errors.

EMR’s and charting are becoming a bigger part of an ever changing aspect in the world of healthcare and should be used more in the Emergency Department at GLWACH and in all Emergency Departments across the nation. With further research looking into ways to fix any glitches and provide continued upgrade of systems, EMR’s have the potential to reduce health care costs, improve efficiency, and to enhance the quality of care and patient safety that is provided by the nurse and the rest of the medical staff in the Emergency Department. At this time GLWACH Emergency Department does use paper charting but the paper charts do get scanned and uploaded onto a computerized system to be made part of their permanent EMR.

Speaking of charting and changes in health care, I think Electronic Medical Records(EMR) has changed the entire health care world. The way of charting by paper is long gone and computerized records has taken over. I remember back in the day, 1989, nurses would complain about having to write so many notes. I have to chuckle as I am writing this, I can remember checking all my patients in the beginning of my shift, and then I would sit down with up to 15 charts piled up next to me, and I would start my charting. Back then, we could do a task and then chart it when we had the chance, which could be the end of the shift. Now, we have to chart as we care for the patient. I guess you can back chart, but then the time is noted as to when you charted

You are currently working in an office with the best equipment possible for dentistry. Your office has a crown making machine, digital x-ray machines and a brand new beautiful facility to complement a professional environment. However, life can change rapidly and someday you may be working in a less than ideal environment. I took an online class with a dental hygienist in San Francisco, and she was hand dipping all of the film in her office. They did not even possess an automatic processor. It is important to learn about film processing in a darkroom, even though it is not valid for your current state of employment. Also, this information will be part of your testing for certification.

The role of the informatics nurse is changing to be important in providing safe quality care to patients. Historically, nursing informatics was believed to be using computerized technology for charting. Today, this role has changed to a technology that is used to provide patients and families with high quality and safe care by using up-to-date and accurate information through data information (AORN, September 2013). The role of the perioperative informatics nurse is to improve the quality and safety for patients during their care in the surgical suites. These measures can be obtained through retrieving and reviewing data that is obtained through electronic health records. The responsibility of the informatics nurse is to reduce the medical errors from occurring by three different methods. Gathering and analyzing data to determine ways of preventing medical errors or adverse events from occurring, facilitating a rapid response when events occur, and providing feedback to the staff regarding the data collection. These three areas will reduce the potential for further events from occurring within the department. Overall, the surgical arena is considered to be a unique and complex area that has a high incidence of adverse events. Examples of common events that can transpire are related to; patient identification, surgical site identification, and medication errors or omissions (Jacques, P & Minear, M., August 2008).

The primary responsibility of a scribe is to complete each patient’s note from the time they enter the ER to the time they leave. I essentially followed my assigned physician for the entirety of the shift documenting charts. I watched the initial patient interviews and physical exams. I took advantage of the opportunity I had to ask the doctors why they ordered certain tests following each patient encounter. I tagged along as they read x-rays and reviewed CTs. I watched a variety of procedures from laceration repairs and joint reductions to lumbar punctures, intubations, even a gastric lavage. If one of the other doctors was doing a procedure that was rarely done in the ER, I made an effort to try to watch. Doing this I was able to see things

Emergency Medical Services predefined relationships, with hospitals, contributed to emergency room overcrowding. Researchers found that hospital selections were based upon the coverage needs of Emergency Services and not the needs of the facility. Service type, single response or multiple response, and service size were indicators of hospital selection. Data suggested that patients were that patients were transported to hospitals according to their zip codes. Patients located within high income zip codes were frequently transported to higher cost per patient facilities also located inside of the high income zip code. Whereas, patients located inside of lower income zip codes were frequently transported to lower cost per patient facilities

In my daily practice, I see the providers (MD/APRN/PA) charting in the electronic health record (EHR), as much or even more that the nursing staff. The estimates for time spent charting for both nurse and providers are about the same three to four hours a day. Provider documentation is more focused on note writing; while nurse documentation is task-driven to flowsheet documentation (Penoyer, 2014). In the OR I am not sure how nurses are documenting intraop, but our Anesthesiologists and CRNAs, are documenting the entire case in the EHR. When we went live with a new EHR in 2014, it changed perioperative workflow dramatically. We still struggle with workflow issues, such as back table meds and tissue management.

Ineffective nursing documentation compromises patient safety and can result in serious or even fatal errors. Nursing documentation is essential to practice and is defined as everything entered into a patient’s electronic health record or written in a patients’ record (Perry, 2014). The goal of effective nursing documentation to ensure continuity of care, maintain standards and reduce errors (Perry, 2014). Nurses are accountable for their professional practice which requires documentation to effectively reflect the care that clients receive. The College of Nurses of Ontario (CNO) states that nursing being regulated health care professionals are accountable for ensuring that their documentation is accurate and meets the practice standards (College of Nurses of Ontario, 2009). Effective documentation strategies to reduce errors include; documenting in a timely fashion, using correct abbreviations and spelling, correcting documentation errors appropriately and ensuring that handwriting is legible. The purpose of this paper is to explore these strategies in greater detail with the goal of improving the care nurses provide to their clients to enhance safety.

Medical errors caused by human oversight are the main issue inside Emory Healthcare. In 1986, it was calculated that 37% of the patient cases had medication treatment fault. The problems are due to the lack of standard for orders by physicians. Physicians would place orders by hand writing, and then they would call a nurse and ask him/her to write the