Electronic Medical Records and Charting Essay examples

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

Based on the patient safety, patient satisfaction, data, and culture of the institution, it is possible to choose different methods of reducing risk in health care settings. Those methods include ancient methods such flow-sheets, Kardex, sticker reminders, checklists. The EMR is a new and convenient method to mitigate error in health care settings.

The electronic medical record system (EMR) serves many purposes in an emergency for the patient, physicians, and hospitals involved in the diagnosis and care during an emergency.

EMR stands for Electronic Medical Records. It is “a paperless, digital and computerized system of maintaining patient data, designed to increase the efficiency and reduce documentation errors by streamlining the process.” (Santiago, n.d., para. 1)

But the information in EMRs doesn’t travel easily out of the practice. In fact, the patient’s record might even have to be printed out and delivered by mail to specialists and other members of the care team. In that regard, EMRs are not much better than a paper record (Garret and Seidman, 2011).

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

Core concepts include, what is the Electronic Health Record?, how does the Electronic Health Record relate to nursing informatics?, what is the significance of the use of the Electronic Health Record?, who benefits from the use of the Electronic Health Record?, and how secure are the Electronic Health Records? An initial understanding of the core concepts will provide the foundation for understanding how the Electronic Health Record is transforming the way nurses provide patient care.

EMR concerns are plaguing the health care industry today that requires change. Healthcare professionals, such as nurses, are on the front lines in the defense against medical errors. Closing the gap between current clinical and hospital practices and the various approaches to improving patient safety requires changes that are cultural and systemic in nature. The greatest challenge to hospitals using an EMR system is the expense of the new system, and the challenge nurses face with technology adoption in usage of EMR and protection of records. Even though spending depends on both the hospital size and the technologies were chosen, implementation and installation of a Health Information Technology system, which includes EMR, are often multi-year investments. The transition from a paper-based system to an electronic system is a very complicated process within every hospital establishment. The transformation is time-consuming and involves numerous staff from across the hospital, including Information Technology personnel, physicians, nurses, ancillary providers, etc. Although hospitals work hard at managing the changes required to move toward an electronic environment, there is no guarantee that hospital personnel will properly utilize the expensive new IT system or EMR. Therefore, the training in the EMR integration is required to all medical staff to have an efficient and uncomplicated system.

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 current medications, allergies, laboratory results, diagnoses, immunization dates, images, treatments, and medical history (“Learn EHR Basics,” 2014). The purpose of the electronic health record is to have a patient’s health care record available to health care providers nationwide, but the patient can decide who has access to their record (Edwards, Chiweda, Oyinka, McKay, & Wiles, 2011). The electronic health record is a very important technology in health care and it impacts nurses, nursing care, and has a significant impact on patient outcomes.

Electronic medical records can benefit patients in many ways. One major way it can benefit a patient is the efficiency of the records being organized and easy for any practitioner or staff member to read. EMR can lower the risks of

Besides the disadvantages of (EMR)’s the advantages pose great benefits to patient care and efficiency. The greater use of electronic medical records or health records can reduce wait times, of seeing doctors or waiting for test results. All staff would need to cohesively work out the technical challenges and software data. With sophisticated IT

The EMR system is better for some doctors because it eliminates the unclear handwriting, thus cutting down on the unclear writing mistakes by doctors. The patients have been released from the hospital at a rate of at least one day earlier than the patients with paper records and these bills were almost $900.00 less than when they used the paper records. There have been many deaths each year because of the wrong medication being written on the prescription paperwork and a pharmacist misread the handwriting on the form. If this information is typed the chances of making a mistake are less. There are also EMR systems that diagnose diseases and treatments, which is another advantage. Just imagine how fast the patient can be healed if a computer program can predict the results of an illness by entering the symptoms such as a device that searches for glaucoma via computer generated images, the analyzing of mammograms and the ultrasound device to analyze lumps in a females breast that determine if it is benign or cancerous. Most of the time these computer systems have accuracy rate of 80% or more which is the last advantages that we will talk about today.

Implementing customized radiology EMR software modified to fit your practice can transform productivity and efficiency to improve both workflow and patient experiences. Paper-based systems have pain points that frustrate staff members and create bottlenecks that slow down collaboration and delay patient treatment. Making digital information available directly from an EHR patient chart encourages collaboration and informed-consultations in real-time, without waiting for printed records and films – or CDs – to be delivered via mail or courier.

The healthcare industry benefits from Electronic Medical Records (EMR). Electronic software is used to store and transfer patient health records. The advances in technology allow healthcare professionals to access and share patient medical history. Such a system may decrease health care costs, increase the quality of patient care, facilitate better departmental communication, create less paper confusion,

Electronic medical records had a great impact in the ushering in of the age of Nursing Informatics. (Himss, 2010)EMRS present healthcare professionals with the ability to retrieve and organize data in a quick and efficient approach. With information so readily available, patient safety increases and we know that patient cost goes down. This happens because patient medications, allergies, history, demographic, and treatment information is more collectively available.