The Ethics Of Adopting Electronic Documentation For Patient Care

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.

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 university of Arkanaza is preparing future nurses for using EHR and evidence-base practices by peaking the interest of health professional through training and seminars. As describe in the previous article is important for the facility providing education to future nurses to maintain a level of positivity about electronic health record. Educational organizations need to be onboard with this new technology to better serve patients efficiently. EHR, is important part of reducing errors, patient safety, and improving standards of care. As nurses its important to maintain a level of honesty and accountability. The use of EHR gives nurses the opportunity to promote proper documentaiton standdards for nurses and other care professionals. The

There’s no denying that EHR has advanced the quality of healthcare by improving the way information is accessed and exchanged. But despite these advancements, errors, which were simply not tolerated in paper records, are numerous in EHRs. Because of this, electronic documentation tools have been developed in an effort to increase the quality of clinical documentation, enhance communication between healthcare providers, and improve delivery of care.

Therefore, several authors share some of the same ideas as to what some of the barriers faced during the transition to Electronic Health Records (EHRs) and if these barriers still exist once the transition to a full EHR system is complete. Herrick, et al., 2010, states that currently, there is no hard-core evidence to support the argument that Electronic Health Record (EHRs) and Health Information Technology is the best route for health organizations to prevent errors. In fact, the use of such technology could potentially lead to errors if information incorrectly entered in the system and Haupt, 2011, statement that smart software could help to prevent life-threatening errors better when administering medicines. Whereas, Boonstra & Broekhuis, 2010, states from a physician point a view need the understanding of the possible barriers that faced during implementation of EHRs because there a tremendous amount of literature on the obstacles but no suggestion on how to resolve these barriers have not been viewed. Barriers such as, financial on great startup and ongoing cost, technical and time to train staff and how much knowledge do they have with computer skills and psychological when support needed from vendors, etc. It suggests that once those barriers have been ironed out and a plan has set in place, then the transition from paper documentation to Electronic Health Records (EHRs) may go a lot easier for the healthcare arena physician, nurses and administrative

Many health care facilities are already starting to use an electronic health record in some of their departments. An electronic health record is a system that allows health care employees to input patient information into a computer system and saves that information into a database for the facility. The information that is being stored directly into the computer system is patients’ personal information (name, date of birth, address, emergency contact information, insurance information, and primary care physician and/or admitting physician), medical history, allergies, current medications, nurses and doctors’ notes, and other information that may pertain to the reason for the visit. Radiology and lab results are also saved into the electronic health record. Even though some health care facilities use a computer system to save some information, there may also be paper work that is also being used. This paper work is scanned into the facilities database so that it can also be saved and viewed if necessary.

Collaboration and communication between patient’s, their physicians and the health care team are required in order to preserve the safety of the patient. Improper use of EHR can produce errors that may possibly threaten the reliability of the information in the EHR which may endanger patient’s safety thus decreasing the quality of care. Healthcare quality relies on the accuracy and integrity of the patient’s health information. One manner EHR accuracy may be-threatened is because of the growth of members of the healthcare team copying and pasting text documentation. The copy and paste process poses a risk to the integrity of nursing documentation. Risk such as, redundant documentation, outdated documentation, and inability to identify when

When walking into a doctor’s office, are nurses taking your information manually or electronically? Although, some offices still use paper records, many are making the transition to Electronic Medical Records. Electronic Medical Records is a digital form of medical records. New technology is developed every day and Electronic Medical Records are simply a way to make offices more efficient. Electronic Medical Records helps offices in many ways. They are easy to access, reduce storage, improve accuracy, and reduce cost. Electronic Medical Records are more convenient and easy to manage within a provider’s office.

Many of the hospitals have changed over to everything being electronic. Nurses use computers every day by using an electronic medical record. Nurses can obtain a patient’s past medical history, current and past medications, treatments that were carried out, access to health literature pertaining to a certain assessment or diagnosis, and your assessment of a current patient. The nurse needs to know how to access the right information, how to retrieve and store information to make the correct diagnosis of the patient. The competencies are important for a nurse because so many nurses lack information technology skills, which can limit their ability to access evidence-based information that could otherwise be incorporated into their daily practice (McGonigle pg.

This nursing process has evolved to promote effective communication between health care professionals, a venue for analysis of health care, a source for continue nursing education, and the legal document of the patient’s medical state. Since computers were introduced in healthcare, nurses have optimized documentation adapting advance systems to help them with work and have understood the advantages of shifting manual documentation process to an electronic one and with these hospitals have turned to vendors to come up with a more customized and friendly system to facilitate nursing

Adaptation theory services reach almost every corner of the world. The theory has always served patients and nurses from many nationalities and backgrounds. Irrespective of human interests and backgrounds, nurses who have embraced nursing education and Adaptation theory provide equitable services to all patients at the same magnitude and strength. In fact, the theory organizes annual training refresher seminars where we attend to nurses of all kinds as they bid to refresh their service delivery to patients (Basavanthappa, 2011). The education sessions mainly involve utilization of information technology gadgets and ideas. Moreover, nurses apply most of their skills by use of information and technology as they attend to patients. Therefore, information technology is critical when it comes to management of nurse education and Adaptation theory approaches.

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.

The specific problem this research paper addresses is whether the establishment of state standardized documentation protocols can reduce poor documentation of care in hospitalized in-patients in acute care facility. The significance of this clinical problem is to show that state standard legal document protocols can lead to better patient outcomes and improve quality of care. Nursing documentation of care is very important in patients outcome, hospital administrators, practitioners and researchers regards recordkeeping as a crucial and valuable component resulting to compliance, continuity care, safety and quality of care. According to Okaisu, E.M., Kalikwani, F., Wanyana, G. & Coetzee, M., 2014), “to achieve improved documentation, broader changes were necessary, including building a critical mass of competent staff, redesigned orientation and continuing education, documentation form redesign, changes in nurse skill mix, continuous leadership support and legal monitoring”. Assessment in nursing care is the initial standard of

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.

In today’s medical field technology plays a big role when it comes to patient care. Technology is huge when it comes to giving the patient the best type of quality care when they are in the hospital. In the old days people would just write it down on a sheet of paper and record it by hand, which caused mistakes. Now with the Electronic Health Record those mistakes are drastically declining. Statistics have shown that using the Electronic Health Record has lowered Nursing mistakes as well as improved patient care. Our society has progressed through the years and has been introduced with the Electronic Health Record which has drastically improved our health care system. The Electronic Health Record provides great communication between