- How can an EHR positively impact the quality of nursing care?
- What are potential concerns that EHRs bring to nursing care quality?
- How can these concerns be addressed?
- Identify an idea to improve nursing care quality described by another student that might be useful in practice and tell how this intervention could benefit your practice and use of EHRs.
- Use your personal experience, if it’s relevant, to support or debate other students’ posts. If differences of opinion occur, debate the issues professionally and provide examples to support your opinions.
- Guidelines:
- Please post an original response for this forum. The original posts require (1) scholarly discussion, (2) consist of a minimum of 500 words, and (3) a minimum of 2 current peer-reviewed sources that were used to support the response. The source is to be presented in APA format with in-text citations and the full citation at the bottom of the original posting.
Overview
In order to maximize efficiency, maintain patient safety, increase clinical results, and promote inter-professional communication, clinical recording is required. In order to support the multidisciplinary teams in providing excellent care, nursing documentation gives an accurate picture of nursing evaluations, care plans, changes in clinical status, care provided, and essential patient information. To transmit correct, timely, and organized information regarding patients and organizational tasks, nurses employ precise documentation formats.
The most popular of these formats is Electronic Health Records (EHR), which is used to provide the medical staff with real-time patient status updates. The EHR of a patient provides important data that aids the medical staff in making decisions and ensuring high-quality care throughout the course of the patient’s care.
Current data on patient assessments, clinical issues, clinical reports and lab results, communications with other health care professionals regarding the patient, medication records (MAR), immunization dates, allergies, radiology images, patient clinical parameters, patient responses and outcomes, and the patient’s entire medical history are all contained in an EHR.
Since thorough, timely, and accurate medical record keeping ensures that patients receive the right treatment at the right time, nursing documentation using EHR is crucial. Any nurse would find it impossible to recall every detail of their shift. Without clear and accurate nursing records for each patient, handover to the next team of nurses will be incomplete. The best records include pertinent details regarding the patient’s state at any given time as well as the actions the nurse took to meet the patient’s needs.
