New Electronic Health Records Helping Staff

In a healthcare world that operates on stringent budgets and margins, we begin to see the need for a higher capacity healthcare delivery system. This in turn puts pressure on the healthcare organizations to ensure higher standards of patient care, and compliance with the reform provisions. However, these are the harsh realities of today’s healthcare environment, a setting in which value does not always equal quality. The use of technology can help to amend some of this by providing higher capacity care without compromising quality; this can be done with the use of such technology as electronic health records (EHRs). This paper will aim to address how EHRs influence healthcare today by expanding upon topics such as funding sources, reimbursement methods, economic factors, socioeconomic factors, business influences, and cost containment.

With and pro there is a con in most situations and this too is true when it comes to having an EHR system. One of the cons is the amount of cost it has on a facility to do this that includes things like the cost to switch, train, and purchase the system. The average cost to invest normally rates close to ten-thousand dollars per physician employed in a facility. After

In 2009, the Health Technology for Electronic and Clinical Health Act (HITECH) of 1996 was expanded. This expansion included mandated guidelines for health care systems in the Unites States to continue implementing of Electronic Health Records (EHR) in health care settings by 2016 and added a provision to improve protection of patient health information through privacy and security Turk (2015) . The implementation of this program has created a debate in the medical community. In addition, many healthcare organizations and institutions have conducted research studies and surveys to evaluate the effects of the EHR on documentation of care and other aspects of the EHR. Challenges surrounding the HER include, the cost of implementing EHR’s, time spent performing documentation, and patient outcomes and safety and security concerns. Let’s further delve into a few of these challenges.

The pharmacy, nursing, and informatics department were required to be involved in implementing the bar-code-assisted medication administration (BCMA) patient safety initiative. The involvement of the informatics department was required for planning and coordination of the electronic medication administration record and the scanning devices. The nurses were administering the medications so they were required to undergo training on BCMA methods and the importance of BCMA implementation. Pharmacists were needed to assist nurses in case if a scanning error occurred. Pharmacy, nursing, and informatics staff members were responsible for evaluation of the BCMA system upon implementation.

Medication errors are among the most significant cause of patient injury in all types of medical errors (Johnson, Carlson, Tucker, & Willette, n.d). In the nursing profession, medication administration errors occur 34% of the time, second only to physician ordering errors (Gooder, 2011). The introduction of information technology, such as the Bar Code Medication Administration (BCMA), offers new opportunities for reducing medication administration errors. BCMA was developed by the Veteran’s Affairs Medical Center in 1998 to help improve the documentation of medication administration, decrease medication errors and provide

The following articles were reviewed for the purpose of addressing bar code scanning in medication administration. Nursing requires the critical skill of accurate medication administration. The use of electronic medication administration has brought about many changes in the healthcare field. The article,” What Determines Successful Implementation of Inpatient Information Technology Systems” (Spetz et al 2012), was reviewed to address the above question. Computerized patients records and bar-code medication systems continue to gain favor in healthcare. This idea spread across the nation in all VA sites (Spetz et al., 2012, p. 157), providing a safer environment for patient care.

In the journal article, The Impact of an Integrated Electronic Health Record Adoption on Nursing Care Quality, they discuss how technology can improve quality of care. With electronic health records, nurses can document while at the bedside. Their study confirms that the use of electronic health records can improve patient quality of care (Walker-Czyz, 2016.)

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.

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.

Bar code medication administration (BCMA) is a mechanism to decrease medication mistakes through scanning a code printed on the patient’s armband and then scanning the medication (Leapfrog Hospital Survey, 2016). The scanned information is processed through the electronic medical record and displays on the medication administration record (MAR) to ensure that bedside nurses are using the “Five Rights of Medication Administration” (Leapfrog Hospital Survey, 2016). The process of passing medication to patients has moved from a printed medication administration records and medication carts to an electronic version with automated medication dispensing systems. This electronic version effects nursing care by

Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to

Nursing in today?s society involves more than technical skills, critical thinking, and compassion. It also is changing to add the ability to not only understand but be able to utilize technology to impact a patient?s health. There are many technological changes employed in healthcare practices, however, I have chosen to address bar-code medication administration or BCMA. According to an article in the Journal of Patient Safety, ?bar-code medication administration has been shown to be effective in reducing patient medical errors, yet is still only utilized in 5% of the country?s health care facilities? (Sands, Slebodnik, & Young, 2010). Medication errors are common in hospitals and often lead not only to patient harm, but also lengthy hospital stays and law suits. ?One study identified 6.5 adverse events related to medication use per 100 inpatient admissions, more than one fourth of these events were due to errors and were therefore preventable? (Bane, et. al., 2010).

This paper will identify the use of Electronic Health Records and how nursing plays an important role. Emerging in the early 2000’s, utilizing Electronic Health Records have quickly become a part of normal practice. An EHR could help prevent dangerous medical mistakes, decrease in medical costs, and an overall improvement in medical care. Patients are often taking multiple medications, forget to mention important procedures/diagnoses to providers, and at times fail to follow up with providers. Maintaining an EHR could help tack data, identify patients who are due for preventative screenings and visits, monitor VS, & improve overall quality of care in a practice. Nurse informaticists play an important role in the

When you look at how nursing documentation affects patient outcomes consider all the benefits of informatics. Electronic charting systems allows for automation in patient safety issues. This automation can be prompts that forces a nurse to address things like abuse history, and many other requirements from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), and if the nurses document, there is a history of abuse, the system can automatically send a referral to a department to follow up on the nurses charting. The clinical systems store valuable information, and re-populates, this information on later admissions. An example of this valuable information, would be a patient with the diagnosis of methicillin-resistant staph

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.