Research Paper: Nursing Electronic Medical Records, Documentation

Pages: 10 (3320 words)  ·  Bibliography Sources: 10  ·  Level: College Senior  ·  Topic: Healthcare  ·  Buy This Paper


[. . .] Many states are now requiring hospitals to publish their performance data online, arming patients with information to help them choose where they want to spend their health care dollars (Robles, 2009).

This is important because the courts have realized that personal control of sensitive information is paramount. Although there is not Constitutional guarantee of privacy, the privacy of medical records is an important factor in recent healthcare law.

The use of EMR makes the nurse's job easier in the whole even if the individual is not initially comfortable with the format. Robles (2009) lists other advantages that prove the efficacy of the systems regardless the reluctance of some individuals to accept it. Namely,

"In addition to increased availability of patient information, major benefits of the EMR include improved billing accuracy, improved interdisciplinary communication resulting in improved continuity of care, evidence-based decision support, improved documentation, enhanced legibility, reduced duplication, and improved speed with which orders are implemented. There are real opportunities for automating, structuring, and streamlining clinical workflow."

Nurses want to go home on time and this means that they have to be able to make report to the next shift in an efficient manner. EMR helps both the outgoing and oncoming shift make a more seamless transition. It does not matter if the previous nurse charted efficiently or not because the activities of the shift can be read from the EMR rather than having to rely on another person's memory.

Another issue is ease of use because the individual has to be sure that they can get the information that is needed without a great deal of hassle. This all comes down to testing the various systems to see which one works the best for that particular group of people (Pinto, 2006). If the nurses and doctors (and whoever else will utilize the system) are not comfortable with it, then it is a failed system. The advantage here over paper is that the systems are getting much easier to use, and charting on computer makes it easier to edit the document, and access other tools that may be needed for its completion.

Nursing role in implementing and utilizing EMR

Nurses have a pivotal role in the selection, implementation and use of EMR technology whether it is to be used in a clinic or hospital setting. The reason for this is that nurses will be the primary users of the technology. Implementation of a technology can have good and bad results just like the technology itself. The nursing staff needs to understand what they require of the system before they can be effective advocates for a particular EMR type. "A successful EMR implementation depends on an organization's infrastructure" (Bernd & Fine, 2011). The clinic or hospital must have a mission and vision that is compatible EMR system because there are differences in how they operate. There are also some "maxims" that must be followed during the implementation of the new system. They are: "A successful implementation depends on great planning and great execution; When profound change is involved, disruption should be anticipated; and Comprehensive EMR implementation is only possible through strong, clear leadership" (Bernd & fine, 2011). However, there are some pitfalls that can be avoided if the planning phase goes the way it should. One should "Never Underestimate a Good Support System," realize that "Real time and role-based support is critical to a successful launch," and "Success can be measured in quality and efficiency" (Bernd & Fine, 2011). All of these factors should be used to make sure that the proper system is installed and that all of the nursing staff that are going to use it are comfortable with the one being installed.

Bedside nursing streamlined with EMR

It does not take long to understand one of the major benefits of EMR implementation to both the nursing staff and the patients in a hospital. Hospitals are largely understaffed and nurses are overworked with all the responsibilities that they have. This means that something has to suffer, and it is usually direct, patient contact. Many say that they got into nursing because it was a way that they could interact positively with people, but that aspect of nursing is fading (Thede, 2008).

Because this is an issue that many see, nurses are generally excited when they start using a new EMR method. Actual bedside care is streamlined so that the nurse is able to spend more time with the patient than previously. So much time is taken up in accurately charting that the nurse often has to leave the patient and do this vital chore. With the advent of EMR, the nurse still has to chart, but he or she is able to access all of the records needed on one tablet, and write the charts much more quickly. Many EMR systems have templates for charting that make the whole process much easier.

Template documentation in EMR vs. free text documentation

However, there is a discussion about whether the template-type of charting restricts the nurse too much. Some believe that the template method is much easier because it takes away some of the thinking aspect and makes it more automatic. But, some nurses enjoy the freedom of "free text" documentation. It is basically a preference and most systems will allow a nurse to document either way.

JCACHO Guidelines for EMR Charting and Documentation

Regardless the type of charting that a nurse does he or she must still follow the guidelines that have been imposed. The JCACHO (now simply called The Joint Commission or TJC) is an organization which accredits hospitals and other healthcare organizations. This is important because it is necessary to have a singular body that sets standards and has responsibility for the maintenance of such. TJC has become so recognized that it is often necessary for a healthcare organization to maintain its certification to stay in business. The mission statement is "To continuously improve health care for the public, in collaboration with other stakeholders, by evaluating health care organizations and inspiring them to excel in providing safe and effective care of the highest quality and value" (TJC, 2012).

Institutions Using EMR

TJC works with all types of healthcare clinics to endure the standards that they are setting. This means that there is continuity across the board in these organizations. Among these are places such as local pharmacies, doctors clinics and others that use various forms of EMR (EPIC, VISTA, and others). VISTA is the accepted EMR used by all government clinics in the United States (Rowley, 2010), but the most popular is EPIC (Kelsey-Sebold Clinic, 2009). Because of its ease of use, and the standard features that are much easier for a clinic setting, it is the most accepted form of EMR among clinics. The primary reason for this systems use is that it "facilitates ease of consultation and care coordination" (Kelsey-Sebold Clinic, 2009). It can be used across a large system, and has the power to maintain millions of records and billions of pieces of vital information.

Comparison of EPIC and VISTA

The primary consideration in choosing a system is comfort. This means that the staff who is going to be using the system needs to be consulted before the system is set in place, and they need to be an integral part of the process of making sure that the system meets all of the requirements that were set. The nursing staff will be better able to discuss quality of care issues than the information technology department of the hospital or clinic, and show the benefits to the patient.

One of the primary benefits to patients is that all of their medical records are available instantly. It would not matter if an x-ray was taken ten-year ago and 2,000 miles away, if it were electronically captured it would be available to the new care facility as soon as they received a release of information signed by the patient or guardian. The benefit of this type of access is that there may be some immediate need for the physician to know how the patient responded to a treatment in the past, or if they had experienced some type of injury or reaction that could influence the present treatment protocol. Paper records do not allow a nurse or physician to have instant access and this could be critical.

Another advantage of new EMR systems is that they allow the nursing staff to have access to all hospital departments at a touch. This allows them to know immediately if the patient has been called for some alternative treatment and when. A handheld device can also carry a great deal of information such as the PDR, for drug interactions, and other needed information that can be had immediately. Some handheld devices are also provided with the means to post vital signs and other information from machine to machine. The nurse does not have to worry about an error in… [END OF PREVIEW]

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Nursing Electronic Medical Records, Documentation.  (2012, April 10).  Retrieved August 22, 2019, from

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