Nurse Workflow Summary

In fact, in some instances, doctors find it more difficult to complete with their already hectic and demanding schedule. The article describes the medical records used in the UK which is an envelope of information that follows a patient their entire life. The providers know what to expect when viewing these records and are able to efficiently and effectively use them as a resource when seeing patients. A main takeaway from this article regarding medical records from the UK is that they must be well kept and organized and also keep the same geographical layout and consistency to be effective. By gathering and reporting information in this way, it allows the provider to be concise. The short notes are almost like clues for a future provider about what the previous encounter entailed and how the issue has progressed or regressed. The article discusses VAMP, the “Value Added Medical Products” computer system which is how the United Kingdom does electronic medical records. Their goal was to replace paper records with this type of system, however it did not work out that way. In this type of reporting, there is both a medical file and a therapeutic file which allow the doctors to separate what they are recording. There are many negatives and positives of a computer system such as this one such as it may remind a physician of a treatment or prescription that was given

Implementation of a computer system to replace paper documentation would require the involvement of an interdisciplinary team. This team would be comprised of several members, each with a specific job. The first member selected would be a Clinical Nurse Informaticist. This team member would be charged with giving valuable input on the software needed for nurses to properly care for and chart on their patients. With the knowledge of nursing practice and informatics, this team member would very valuable in bringing the two together in the most efficient way possible. The next team

Documentation plays a vital role in research, education, quality assurance and reimbursements for both patients and providers (Okaisu, Kalikwani, Wanyana, & Coetzee, 2014, p. 1). The importance of documentation is not lost on any RN, but continuity in what is recorded and what is absolutely necessary to have in a patient’s record is not always met.

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.

This process paper will evaluate the complex relationship between disease pathophysiology and how it has progressed to the patient’s current state of health. It will include a comprehensive discussion of chronic and acute problems leading to the patient’s hospital admission, a complete description of interrelationships and pathophysiology for all medical diagnoses, a comprehensive discussion of the client’s signs and symptoms and results of all diagnostic studies to the underlying pathophysiology, and a comprehensive listing of all medications ordered at the time of admission with explanations of why each was ordered and identification of the most common side effects which may

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

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

Record-keeping and documentation are a hugely important part of nursing practice that unfortunately is often overlooked. Good record-keeping is in fact an essential element of being a good nurse. This assignment will discuss the importance of record-keeping in the healthcare setting. Record-keeping is vital for three main functions of nursing. It facilitates communication, promotes safe and appropriate nursing care and meets professional and legal standards (CRNBC 2008). These purposes and other important functions of record-keeping will be described in this assignment. The professional and legal implications of poor record-keeping will also be outlined. The topics will only be briefly and broadly discussed due to word count

The authors conclude that in order to collect data for meaningful use, one must get back to nursing basics to satisfy regulatory requirements. Under direction of a nurse informaticist, utilizing electronic health records helps facilitate this.

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

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.

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

What is workflow? Workflow is term that’s broadly thrown around across the board with no one clear definition. If I was asked to nail it down I would define workflow as any process or product that aims to streamline the daily workings of the office. Medical offices in particular benefit from efficient workflow as there are many non-revenue producing procedures that must be completed before a physician can even begin to focus on patient care or in other words to make the practice profitable. As you continue to read I am going to talk about EMR (electronic medical records), one of if not the most important innovation for healthcare in general and how this new technology has revolutionized patient management and drastically improved the daily

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

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