The Electronic Health Record

The Electronic Health Record

My preconceived thoughts about the electronic health records in nursing is that thye are primarily there to document that care was completed. It is to cover onself legally to state that care has been completed and documented for continuity of care. The electronic health record is helpful to patient outcomes because nurses and doctors and other healthcare workers can access the patients information from anywhere in a hospital. When a patient is transferred between units, their information moves with them via the EMAR, ensuring continuity of care. In addition to the information in the EMAR, the receiving nurse will get report on the patient.

The HIE used to be in the form of a paper chart. Vitals were taken on a paper chart and patient information was handwritten on report sheets as official form of documentation. There was a lot of filing involved. It then turned electronic, reducing the need for large files on patients and enhancing continuity of care because it is easier for tangible paper files to become lost in translation, however the practitioner can almost always obtain access to the EMAR if they are at a computer within a healthcare facility that has a program such as EPIC. This transition to electronic most likely shifted the nurses role towards more documentation than before, but in some ways it can increase patient safety through increasing healthcare provider awareness of the patient’s condition changes.

I thought that the HealthInfonet will definitely be a tool that I will utilize in the future especially if I am looking for more information on the patient than is provided by the EMAR that is right in front of me at the moment. For example, if there are no allergies on file for the patient I could put their name into healthinfonet to see if there are any allergies for the patient on file there. If I find an allergy in healthinfonet for the patient, I would be able to avoid accidentally giving them a medication that could prove to be lethal for them due to an allergic reaction, thus increasing patient safety. That is just one of the ways that an electronic health record could improve patient care. As a new grad, I want to try to get a job in the ICU, a unit where you need to know as much information about the patient as you can to take care of them effectively. It wouldn’t take long in my day to type my 2 patients names into healthinfonet to check for discrepancies between the info on the EMAR from the hospital and the info in the program. It is quick, easy and useful so I definitely foresee it being utilized in my future practice.

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