Electronic Health Records

Amatayakul, M. K. (2009, January 01). Electronic Health Records: A practical Guide for Professionals and Organizations. VitalSource Bookshelf(4). Chicago, Illinois, USA: AHIMA Press. Retrieved August 2012, from <http://online.vitalsource.com/books

Health information technology is a familiar entity for most working nurses in the year of 2017. Many nurses, have lived through the transition from paper charting to online charting. This transition has not always been a progression of ease. Change is never easy. The process of paper charting with pen and paper and the use of paper medication administration records have been the routine process for many years. With the new onset of the electronic health record (EHR) many processes have become easier, safer, and more efficient while some tasks have become more complicated, confusing, and more time consuming. The goal of this paper is to describe the electronic health record system, expand on the essence

Paper-based health records have existed since the time of Hippocrates. The most significant change in paper-based health records occurred in the 20th century with the development of electronic health records (EHRs), due to evolution of technology (Rocha & Rocha, 2014). The development of EHRs began in the mid-1960s. Since that time, EHRs have continued to advance. Many institutions are now placing a greater effort in the utilization of this advancing technology (Atherton, 2011). The main purpose of EHRs is to increase efficiency of care and organize and improve quality of data storage through new resources and applications (Rocha & Rocha, 2014). EHRs play a vital role in the healthcare system, patient care, and

Remember when everything was paper based and computers never existed, what happen to those days? What happen to having to do things manual? Well technology sure has changed and had made things easier and more cost effective in some ways. In the 1980s and the 1990s, Electronic Health Records (EHR) was just being introduced in such organizations such as Intermountain Health Care-Utah, Partners Healthcare-Boston, and Wishard Memorial Hospital-Indiana were among the few to see the quality and efficiency of EHR. (Byers, 2011)

EHRs has been known to be a problem for some physicians or healthcare providers despite of the advantages. Because of this system physicians are forced to perform some time-consuming tasks that could be assigned to someone with lesser qualification, which creates more work for the physicians. Physicians described poor Electronic Health Record (EHR) usability that did not match clinical workflows, time-consuming data entry, interference with face-to-face patient care, and overwhelming numbers of electronic messages and alerts (Friedberg, Crosson, & Tutty). Another issue that was reported is that there are a lot of electronic alerts and people also could potentially misuse the template-based notes which is pre-formatted and computer generated.

The scenario selected for this evaluation project focuses on the electronic health record. The scenario involves patient documentation, clinical decision support, and performing nursing notes. The project involves evaluation and implementation of EHR. The electronic health record and clinical decision support are not only relevant to my current organization but also are particular interest of mine. The electronic health record has helped to reduce the amount of paper which was a nightmare to maintain with the number of new patients being admitted daily. The electronic health record has also reduced the amount of missed documentation and errors. Any clinician can testify to the wasted time and poor communication among providers that sometimes results because antiquated paper records still predominate in our offices and on the hospital wards (Shortliffe, E. H., Tang, P. C., & Deimer, D. E., 1991). The clinical decision support system has been a great assistance to clinicians. Nurses, health visitors and midwives, as the largest group of healthcare professionals, record and generate most of the information used to maintain and improve patient care (Levy, S., & Heyes, B., 2012). Clinical support systems (CDSS) integrate information (ideally from high-quality research studies) with the

Technology has come a long way when it comes to pretty much any aspect of life. It is more convenient to just buy things online instead of waiting in line at a store and have it shipped right to your front door step. With new technological advances comes new ways to commit crimes, such as identity fraud. Just by getting some information about a person they can ruin that person’s identity bring them thousands of dollars in debt. So we know that technology is a good thing but a little more risky when it comes to personal information. That’s what brings me to electronic health records. Going from the standard paper record to the more detailed electronic health record is a step in the right direction, but with that step there are risks that need to be considered. Electronic health records means all your personal information is stored in a data base electronically. What is stopping criminals from breaking into that data base and stealing all your information? That is what we will look at in this paper, the pros and the cons of electronic health records.

Healthcare is a complex entity that encompasses a variety of specialties necessary toward meeting the needs of patient seeking clinical services. There are multiple communications necessary to efficiently meet patient needs. For many years detailed documentation, progress notes, specialty consults, and physician orders have been hand written. The legibility of this documentation was often illegible, and difficult to decipher, which resulted in clarification orders and often delays. The electronic medical record was introduced approximately 50 years ago with an ultimate goal of compiling healthcare information for immediate and future reference (Keller, 2016). Since the electronic medical records was initially implemented multiple versions have since been created. Successfully implementing the electronic medical record, requires a great deal of research to ensure that the specifications align with the organization’s short and long term goals.

Electronic medical records have the potential to transform and develop healthcare in a multiplicity of ways over the coming years. According to Net Health, there are three different ways that specialized EMRs are transforming the world of healthcare today. The first way is the fact that the more accessible data exists in the healthcare industry, the easier it is to make a diagnosis (NetHealth). These diagnoses are not being used in just one setting, however, but in a conglomeration of medical care settings. These include clinics and treatments which are improving the quality of life for breast cancer patients, diabetes patients, chlamydia patients and even colorectal cancer patients (Kern). Electronic records are creating a huge and accessible database to reach information more quickly and more efficiently. As physicians and practices,

In this article, Sherree Geyer analyzes how clinical documentation in this EHR (electronic health record) era is affecting care, and what that means moving forward. Geyer takes a look into what is at the core of the problem that has physicians not connecting the dots on clinical documentation. She also addresses what can be done to ease the situation as we move forward in this EHR era.

Technology and health care have a relationship that has grown exponentially over time. Not only has advances in technology allowed for more treatments and research into cures for diseases, but it has also created a better patient care in hospitals. This is why nurses need to “Demonstrate effective use of technology to navigate the electronic health record, communicate with inter/intraprofessional teams, and be involved with decision making in the delivery of quality and safe patient care” (Ivy Tech Community College, 2016). A study conducted by (use of electronic) found that the most common thing nurses use now to help plan patient care is electronic health records. What was once a stack of paper in a binder is now streamlined onto a user interface, with easier access to what parts of the chart a nurse would need, compared to having to flip back and forth between pages in a paper chart. Hard to read hand writing on paper charts could lead to errors in patient care; nowadays, electronic charts have information in easy to read fonts with important information sometimes bolded or in different colors, allowing the information to better catch the eye of the nurse to avoid mistakes. (use of electronic) also

Nowhere in health care has information services and information technology made more of an impact that at the physician services level. The ability to gather and compare data pertaining to a patient’s health care and their treatment plans has provided the physician with the information necessary, in the right place, at the right time, to properly diagnose and treat the patient. The system that has provided the most information and has been paramount in assisting the physician is the inception of the electronic health record.

In the modern world technology is everywhere and it affects everyone’s daily life. People are constantly attached to cell phones, laptops, and other electronics, which all have affected how people live their lives. Technology is also a large part of the healthcare system today. There are many electronics and technologies that are used in health care such as electronic health record, medication bar code scanning, electronic documentation, telenursing, and there are many more forms of technology that impact nursing. One technology that stands out is the electronic health record. The electronic health record, also referred to as EHR, is an electronic version of a patient’s chart and it contains is a list of the patient’s

Electronic health records (EHR) is more and more being utilized in organizations offering healthcare to enhance the quality and safety of care. Understanding the advantages and disadvantaging of EHR is essential in the nursing profession as nurses would learn its strengths and weaknesses. This would help the nursing profession know how to deal with the weak areas of the system. The topic on advantages and disadvantages of EHR has been widely researched on with different researchers coming up with different opinions. Nurses ought to have knowledge on the advantages and disadvantages of EHR systems for them to use systems efficiently. This would transform the operations of health systems and benefit patients with quality service.

It is important to understand that patients are very satisfied with electronic health systems. For example, patients see a vast improvement in the speed at which they are being seen when they go their doctors’ office. Patients no longer have to wait on their physicians for hours due to the fact that their information can be readily available to their physicians when they come to see them. Moreover, all their information is transparent to their health care provider since all their data is in electronic form.