With An Ever-Changing World, It Is Important To Predict

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

The biggest concern the FBCH emergency department faces while using paper charting is the errors made due to sloppy hand writing, failure to document procedures in a timely manner, and miscommunicated orders. During an emergency situation, providers often rush when writing orders and most doctors have chicken scratch for handwriting as it is without the added pressure of being pressed for time. When nursing staff cannot read an order or misread an order it can cause the patient undo harm. One such case happened in the FBCH emergency room when a nurse at first

A lengthy list of EHR benefits supports the evolution from paper to electronic medical record keeping. One such benefit, the significant reduction of needed storage space. Bulky paper charts require a lot of space and misplaced charts waste time and effort to locate. Since EHR data remains on the computer, medical practices no longer require secure on-site storage, and electronic files eliminate misplacing files. Another benefit to data remaining on the computer rather than a medical chart, electronic records allow immediate access from several locations. EHRs provide emergency room personnel access to allergies and other pertinent information of unconscious patients. The on-call physician accesses patient information from their home computer, rather than driving to the medical

The use of informatics and technology have been really helpful in eliminating the use of paper in documenting care, however; it also came with its own challenges. At the nursing facility where I work we still use paper for medication administration record (MAR) but we use point click care (PCC) for all other documentations like the nursing notes, skin assessment and SBAR. The impact that these changes has on my practice is the fact it makes charting easier as oppose to writing, it also makes the information immediately available for the health care team.

Patient’s information is kept confidential and less likely to have a breach the HIPPA law. Having regular charting system, things can easily get lost. Pages can come out of the chart without knowing really knowing or noticing; personnel’s handwriting may not be legible, which cause confusing for other staff and billing, and the list can go on. With the electronic medical records, the need for paper would be less.

EMR’s and charting are becoming a bigger part of an ever changing aspect in the world of healthcare and should be used more in the Emergency Department at GLWACH and in all Emergency Departments across the nation. With further research looking into ways to fix any glitches and provide continued upgrade of systems, EMR’s have the potential to reduce health care costs, improve efficiency, and to enhance the quality of care and patient safety that is provided by the nurse and the rest of the medical staff in the Emergency Department. At this time GLWACH Emergency Department does use paper charting but the paper charts do get scanned and uploaded onto a computerized system to be made part of their permanent EMR.

With the elimination of paper charts, patients information becomes available with a touch of a button. This information includes insurance verification, current medications, lab reports, and past visit summaries.

efficient than paper having a centralized chart to be more manageable with quicker access to patient's health

Prior to the onset of tablets, the patient chart was the pillar of hospitals for decades. With the patient chart, assessing prior medical records was a huge concerned to most hospitals. As such, physicians found themselves repeating medical tests and procedures resulting to poor outcome. But with the tablet replacing the paper chart or the clipboard, patients can now fill out forms and questionnaires electronically

Electronic charting has become the norm in the medical world and if a facility is not currently charting their patients’ health care data on a computer they are extremely behind in the current trends. Since charting on a computer has become the norm for medical facilities many different charting systems have been developed for health care providers to use to chart their patients’ health care information. Learning how to navigate these systems can be challenging, especially if a health care provider works at several different medical facilities and they all use a different electronic charting program. Some health care professionals have advised that all medical facilities turn to only one software program. They argue that this would make it easier for all health care professionals because they would only have to learn one system to chart on their patients. This universal electronic chart would follow the patient so that it

The concept of electronic health records (EHR) was introduced in 2004 (Sheridan, 2012), and in the 13 years that have since followed hospitals across the United States have adopted computer charting systems. As of 2015, 96% of hospitals in this country are using electronic health records systems (Conn, 2016). It is important for facilities to maintain safe and secure computerized charting to better care for patients and to protect and exchange medical information.

With major opportunities arising in healthcare organizations all around the world future advances in technology are taking over. The new sophisticated, personalized, and rapid improvements allow for more time to actually do what’s important and that is being able to take care and cure patients that need special treatment. Charting is the oldest and most prevalent form of maintaining hospital and other facility records. There is a file room filed with these records that are separated by dividers until converted. Considerably revamping and removing paper charts that are hand written, often misinterpreted and only one individual accessible, creates a more monitored and efficient process of tracking patient records

The health care system has come a long way from pen and paper. An introduction of computers slowly started to change the way doctors and nurse would chart. From paper charts and filing to scanning into the computer and keeping files on a floppy dicks and CDs. Now we are able to utilize an electronic computer charting system and a development of electronic health records. EHR is now a standard of handling information as well as storage and sharing of patient medical information that many people use and some people abuse.

We live in an age where everything is somehow intertwined with technology. In the health care setting technology has been put in place to help nurses and physicians limit their errors as well as become more efficient at taking care of the patient. There are many advancement which have changed over the years and are still changing. One of these advancements is the EMR, Electronic Medical Records. The EMR has allowed hospitals to move away from paper charting and move on to electronical charting which makes it easier for physicians and nurse to monitor the patient. The EMR helps correlate data and trends a patient has, to understand what needs to be done to better their health as well as if the care plan currently implemented is working. Also, it helps doctors and nurses communicate on different floors and different hospitals easily without having to actually travel to the doctor or nurse to show them a copy of the chart. Therefore, making it effortlessly assessable for anyone who needs to see the patients chart.

Clinical Documentation has been used throughout the healthcare to analyze care provided to a patient, communicate important information between healthcare providers and patients, and provide medical records that will help patients track their conditions. The Electronic Health Records (EHRs) have revolutionized the process of clinical documentation through direct care to the patient. This electronic health record is a new technology that helps maintain patient’s privacy and to direct care of the patient. Both Computer systems and EHRs can facilitate and improve the clinical documentation methods, which is beneficial for all patients, the care teams, and health care organizations. In this case, clinical documentation improvement has a direct impact on patients by providing quality information. However, the new technological change can also address the health care system efficiencies that differ from paper-based charting. Obviously, the implementation of clinical documentation is essential to enhance the provision of safe, ethical, and effective care.