Nursing Paper on The Process of Electronic Nursing Documentation

The Process of Electronic Nursing Documentation

The digital era has seen drastic technological advancements with broad applications in diverse fields including healthcare. Before the advent of the internet and technological developments, the healthcare sector used paper records for patient information documentation. However, the technological improvements witnessed in the ‘60s and ‘70s paved way to the development of computers, which, in turn, led to the computerization of patient records. Computer applications were used in patient recording but due to frequent errors, there was need for a viable electronic health record (EHR) system. The EHR system is a “longitudinal electronic record of patient health information generated by one or more encounters in any care delivery” (Allan & Englebright, 2000). There are various devices and technologies used in EHR systems to enable it to perform all the functions of patient documentation.

Before looking at the procedures of electronic patient documentation, it is important to examine the EHR hardware basics. The first device is a desktop, which is a fixed, hard-wired computer that s stationed at a specific place normally on top of a desk or on the floor tower. The desktop computer has a standard configuration system which features a monitor, keyboard, CPU, and mouse. Desktops are available from a wide variety of vendors at affordable prices and since they are standardized, it is easier to find accessories and spare parts for the machines. However, since desktops are stationary, a health facility may be required to install several of them in each room (American Academy of Family Physicians, 2019). They also take up much space, compared to portable devices. The second device is a laptop. A laptop is a computer, which is small enough to be portable. Laptops are advanced: they can utilize both wireless and traditional networks and can connect to a larger monitor as well as a standard keyboard. Tablet PCs are other devices used in electronic nursing documentation. They can be in a form of a slate tablet PC with no attached keyboard or a convertible tablet PC whose screen can be swiveled and folded onto the keyboard. A digital pen or a stylus is used to add information on the tablet, which features handwriting recognition software (American Academy of Family Physicians, 2019).

Once a patient visits a health facility, the first step of documentation is his/her identification at the registration desk. Basic information like name, sex, date of birth, national identification number, social security number, health insurance number, and contact information are entered into an electronic system. Once the information is entered, the registration system automatically assigns the patient a unique number that is only applicable in the specific healthcare facility. Also, upon receipt of a referral, staff in charge will check to determine if the patient is in the system before taking his/her identification details. An electronic Master Patient Identification (MPI) card is used to locate medical records of a previous inpatient or outpatient (American Academy of Family Physicians, 2019). The MPI card contains the patient’s name, address, hospital’s identification number, sex, and age. The search program in an EHR system enables the professional to locate the details of a particular patient. Importantly, professionals should be keen to observe strict security codes to prevent unauthorized access or alterations of patients’ information. Each professional requires personal username and password to grant him/her the right to access, modify, or delete records from a patient’s electronic file. The EHR system captures and manages medical history records of a patient including procedural/surgical details, social and family history, and other available clinical histories. Consequently, this system improves care coordination by integrating and organizing patient information and enables its instant distribution among authorized providers (HealthIT.gov, 2017). The patient’s medical history data allows a physician to determine the effective therapies and look out for major indicators like drug allergies that can harm a patient. Accurate and updated information of a patient is helpful especially when an individual is seeing multiple specialists, requires emergency treatment, or when making transitions between care settings.

Computerized physician order entry is the next step after patient identification. The EHR system is features a physician order entry or CPOE, which is an application used by physicians to order laboratory, radiology, pharmacy services and other physician related orders (Seymour et al., 2014). CPOE allows physicians to order tests electronically without the struggle of putting the writings in paper forms. Once an order is made, a notification will automatically be sent to the area the patient will be arriving. The introduction of CPOE has greatly improved patient care. The technology minimizes the possibility of human error, reduces care delivery time and improves accuracy. Also, the technology has enhanced communication between physicians, nurses, and pharmacists among other clinicians (Seymour et al., 2014). The ordering of services is facilitated by lab information systems (LIS), radiology information systems, and pharmacy systems. The LIS, which is interfaced with EHR patient data, allows the exchange of testing results. The RIS is used with picture archiving communications system (PACS) to capture, store, and distribute medical electronic images (Seymour et al., 2014). PACS feature four components – imaging modalities including MRI and CT, a network to transmit patient data, technologies for interpreting and reviewing images, and archives to store and retrieve images. This ensures timely access to images and their efficient interpretation, distribution, and display, thus, improved care. Electronically integrated med cards are pharmacy systems, which are also interfaced with the EHR system. The technology utilizes bar coding on medications to ensure accuracy in dosage and patient administration. Electronic prescription eliminates handwriting errors that can lead to various inconveniencies including wrong dosage (Seymour et al. 2014).

Admission notes are then entered in the system after the physician reviews test results. The notes would include the patient’s medical history, present symptoms, physical examination results, provisional diagnosis, and proposed tests and care. Clinical progress notes can later be added to document the patient’s daily treatment and reactions. All records are stored electronically and access rights are granted to the authorized individuals only. EHRs also guarantee patient confidentiality. They have built in security systems that prevent unauthorized access of patients’ information. The EHR system also enables other applications that help to complete the patient record. For instance, the system’s accurate documentation of patient encounter allows proper medical billing coding and billing, hence, avoiding compliance problems with commercial insurance companies. The built in diagnosis databases of EHR technology helps coders and billers to generate accurate healthcare claims (Seymour et al., 2014). EHRs also feature technologies that enable notification and reminders of essential clinical requirements like dosing, clinical task assignment and tracking, and provider-patient communication. The systems also have a patient portal to enable patients to follow up their medical reports and fill out intake forms. These functions enhance patient care.

The EHR system features various technologies that ensure safe and efficient collection, storage, and sharing of medical information among care providers. Devices used in the electronic nursing documentation include desktops, laptops, and tablet PCs. The technologies applied enable an integrated services that enable patient registration, physician order entry, and laboratory, radiology, and pharmacy services. EHRs enhance care coordination and continuity, reduce care delivery time, and delivers accuracy. Data storage and accessibility is also safe and efficient due to observed security measures.

 

References

Allan, A & Englebright, J. (2000, Feb). Patient-centered documentation: an effective efficient use of clinical information systems. Journal of Nursing Administration, 30(2), 90-95. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/10689400

American Academy of Family Physicians. (2019). EHR hardware basics. American Academy of Family Physicians. Retrieved from https://www.aafp.org/practice-management/health-it/product/hardware.html

HealthIT.gov. (2017, Sep 15). Improve care coordination. HealthIT.gov. Retrieved from https://www.healthit.gov/topic/health-it-basics/improve-care-coordination

Seymour, T.J., Frantsvog, D. & Graeber, T. (2014, Oct). Electronic Health Records (EHR). ResearchGate. Retrieved from https://www.researchgate.net/publication/267226700_Electronic_Health_Records_EHR