Electronic Documentation Of Patient Outcomes

In the medical field there have been a lot of technological advances and making health records electronic is one of them. The days of having a paper health record are almost obsolete. An electronic health record keeps a patient’s medical information and history on a computer which is accessible to more people in less time. I will explain how the continuity, communication, coordination and accountability of the electronic health record can help the medical office. I will explain what can be included in the electronic health record. As an advocate of the electronic health record I will also explain some disadvantages to the electronic system.

Nursing Informatics is the integration of nursing science, computer science and information science to process and manage data and information in nursing practice. The goal is to promote the health of people, families, and communities through advance information and communication technologies (McGonigle & Mastrian, 2012). The common saying “knowledge is power” is pertinent to this course. Nursing informatics provides nurses with knowledge that will empower them in achieving

Nursing informatics and technology are quickly becoming the hot buzz words for nursing in the twenty-first century. While performing research for this specific paper, the observations of how far technology has come from its inception is mind boggling. When looking back to the mid 1990’s every patient had paper charting. Nurses manually charted vital signs, nursing notes, treatments and all orders were manually written in the chart. The patient’s name, insurance information, and billing items were stored electronically. Fast forward twenty plus years and everything nurses do with, for or to a patient is filed electronically. This file today is known as the electronic health record (EHR) (Lavin, Harper, & Barr, 2015). This paper will be delving into the history of nursing informatics and technology, the pros and cons for nurses and what will be the big picture for informatics and technology in nursing today and in the future. Nursing informatics and the technology that has evolved over time are changing and quickly affecting how nurses treat, communicate, plan and document everything that they do for their patients.

1. a) Nursing informatics is used to inform about what nurses do and how nurses use information to make decisions for patients. Nurses use EHRs to manage patient information (Pritchard, 2015). Nursing informatics allows nurses to remain interconnected with other health care professionals from other disciplines, so that information is seamlessly exchanged between nurses and the rest of the health care team (Pritchard, 2015). Nursing informatics is also used to personalize patient care and to inform patients about their care as consumers and keep them involved. Nursing informatics I also used to improve public health by using better data collection, bio-surveillance, and quality measurement in research to influence patient outcomes (Pritchard, 2015).

Technology plays a vital role in today’s healthcare system. As technology advances the role of a nurse informatics is to combine technology to support nursing care by implementing, converting information, and incorporating data, in order to develop and merge applications and software imperative to the quality of care given through data management and documentation (Darvish, Bahramnezhad, Keyhanian,

The international Medical informatics Association (IMIA) defines nursing as the "science and practice (that) integrates nursing, its information and knowledge, with management of information and communication technologies to promote the health of people, families, and communities worldwide." The application of nursing informatics knowledge is empowering for all healthcare practitioners in achieving patient centered care. (Explorehealthcareers.org, 2015). Nurse informaticists work as

Informatics combines the sciences of engineering, computers, and information with the cognitive health services (Huber, 2014, p. 442). Clinical informatics integrates nursing science with computer science to manage and communicate data, information, knowledge, and wisdom in nursing practice (Huber, 2014, p. 442). Informatics and clinical informatics are similar in the fact that they use technology to for data collection and analysis. However, clinical informatics go one step further by using its data to improve patient care and patient outcomes. My organization uses clinical informatics in several different ways. The two

With the rapid growth in the implementation and use of electronic medical records, there is an increase in how we define the role of nurses and other team member’s (Deese & Stien, 2004). Along with providing optimal care, nurses are also responsible for interpreting and accurately documenting large amounts of information. According to, (Ericksen, 2009) nursing informatics is defined as the integration of nursing, its information, and information management with information processing and communication technology to support the health of people worldwide. In this

With the use of technology at its glance, the use of Informatics in health care systems is improving and benefiting patients, family and the community. Informatics improve research, communication, documentation, diagnosis, education, and preventing of errors in the health care system. The use of paper charting increase errors, loss of documents, which could interrupt patient treatment and safety. Informatics is also useful in keeping patient medical records, track patient treatment, and progress.

Something to question is new electronic health records helping staff take care of patients or is it a burden. Nursing documentation is always necessary because it provides a reflection of what nurses do for their patients. Documentation helps ensures a flow with patient’s treatment team (Linton & Moon). When documentation is not done correctly or efficiently due to the new technologies it can place the patient at increased risk and added cost to the hospital. Many nurses feel too much time is spent on electronic documentation and not the patient. Nurses know that failure to document is hard to defend in court (Morales, 2014). Having standardized documentation in place can dramatically ensure that patients are getting taken care of, and not have to worry about missing or forgotten documentation and potentially finding health trends in the documentations (“The importance”, 2015). New documentation requirements are effecting nurses in a good way to make sure their care that they provide is being reflected on and noticed.

Hebda, T., & Czar, P. (2013). Handbook of informatics for nurses & healthcare professionals (5th ed). Boston, MA:

According to Dr. Ken Majowski (Laureate, 2011) health care informatics has been in existence for at least the past two to three decades. Ozbolt & Saba (2008) state that “in the second half of the 20th century” the focus of nursing informatics was on the development of “a standardized language” (p. 199). In the 1970’s, informatics included “nursing care planning and documentation” (Ozbolt & Saba, 2008, p. 200). In the 1980’s, nursing informatics research and education led to the “establishment of data standards … unleashing the potential of nursing informatics to improve practice” thus giving nursing the opportunity to “translate knowledge to practice via decision support, and to create new knowledge from the data generated in nursing practice” (Ozbolt & Saba, 2008, p 201). In the 1990’s the “Nursing Terminology Summit Conferences” met “to develop concept-oriented reference terminology models for nursing” (Ozbolt & Saba, 2008, p. 203). The 2000’s proved to be a decade of additional progress with the call for “an electronic health record” for every

Technology continues to explode and be analyzed and revised constantly in healthcare, nursing informatics is an area that will continue to expand as nursing continues to change. With health care needs also steadily increasing, it is necessary to compile and retrieve patient information in an efficient manner. Thus nursing informaticist was developed. Nursing informatics (NI) is the very heart of the nursing field, saving and enriching the quality of lives every day. Informaticists engage in various aspects of patient care, essentially acting as an inter face between the nursing and technical worlds. Informatics combined with healthcare is one of the most successful ideas brought to the table and now implemented into any career field dealing with health care.

Technology and innovation have transformed the way people function personally and professionally. In the past, writing and mailing a letter was standard but now most people send electronic messages and text messages to phones. Healthcare has been changing tremendously as well, not only are paper charts and records becoming obsolete, but now many facilities are sharing test results, visit information details, and prescribed drug lists. This move into the digital age has helped improve healthcare by cutting costs in the long-term, increasing efficiency with decreased wait times, and reducing medical errors. This evolving technology expansion, commonly referred to as nursing informatics has created many

As technology has and continues to advance so will the expansion of nursing informatics. Data from (19th annual 2008 himss leadership survey, 2008) hold this statement true showing a steady increase in the implementation of technologies. As computers became smaller, it became easier and efficient for hospitals and physicians office to implement their use. (sutton, 2007)The first computers were large, expensive, and inefficient. Now, computers are compact, inexpensive, and efficient. The smaller technology allows for portability of information. PDA’s are small enough to fit in your pocket. With these small devices, you can look up a patients medication, drug interactions, side effects, and just about anything, you could think of to