Nursing documentations are very important element in keeping the health and safety of the patients while undergoing treatment. This is because it provide the seamless connection in the among the entire health car professional providing the healthcare. For effectiveness and ease of sharing, the Electronic health records are more effective method used for the documentation of the information of the patient so that it can be easily accessed by all the health care providers in the system (Saranto & Kinnunen, 2008).
For long term patients, proper nursing care depends on the ability of the nurses to access quality and accurate information. The nurses have the duty of not only recording the patient information but also sharing it with the doctors for future use. In this regard, the nursing documentation system is very important in should be designed to enhance accuracy and accessibility in patient care provision ( Kern, et al 2012).
Government promotion of the use of EHR
In a study launched by the US government to promote meaningful use of the electronic health information records, the scholars has indicated that this is imperative because the health care facilities will find it easy to use the system when the very costly infrastructure is available. In this process the government initiatives of encouraging the health institutions to use the electronic health records include the provision of incentives of up to $ 27 billion for the comply but on the other hand, the institutions that fail to put the electronic health record system into proper use by 2015 face financial penalties (Michelle, Sara , Kooienga, & Valerie, 2012).
The government of USA is very keen about all the health institutions making meaningful use of the electronic health records because the paper records have some many challenges for both the patients and the health providers. For instance, the paper records not only lack clinical details but being manual and time consuming; it is not possible to generate the clinical details of many patients at the same time. On the other hand, the automated nature of the Electronic Health records has the advantage of being bale to offer very accurate clinical data to many patients in very less period of time. Although the accuracy of the Electronic Health Records is still unclear, with different studies offering variations in the accuracy results, it is important that the health care professionals use the EHR as tools that help in the transformation of hoe the services in delivered to the patients. This is because studies have found that if the notes are taken on paper then dictated onto the EHR system, it brings about lower quality of the information. It is better if the system is used in a structured form (Heiton, Langabeer ,DelliFraine, & Hsu, 2009).
Electronic Health Records has been promoted by the government as being the tool that will help in making the health system in the US a very effective system. It has been noted that the hospitals are slow in implementing the EHR due to the high capital cost required for the Hospitals to invest in the technology. In addition, the financial returns to be accrued by investing in the technology are still uncertain (Richards, 2009). Some literature have argued that while the initial cost of the investment will be a lot for the health institutions, once in place and working efficiently, the system will not only improve the quality of health care delivery but will also significantly reduce the cost of running the health facilities ( Chamorro et al 2003).
Advantages of the EHR in clinical settings
One of the assertions is that in addition to the widespread benefits of IT being able to increase the organization performance by working on the cost unit and overall profitability of the organization. It has also been under consideration if the use of IT in will help in the reduction of the operating cost by enabling the health facility to reduce the staff. finding of a research done indicate that despite the immense benefits the HER adds to the organization like improving communication, promoting timely and accurate documentation of the patients health status, the health financers should not expect to achieve any meaningful reduction of the overhead cost because the staff will still be required to operate the IT (Akrldge, 2000). The system only works to improve the productivity of the staff. The enhancement of the quality of the tools of service may not lead to immediate increase in the financial returns but has very promising gains as the health facility serves more customers due to the efficiency.
Communication and electronic heath record
Many health care institutions are embracing the use of HER in the examination room, storage medical data and sharing of the data (House of Commons Health Committee 2007). This has brought a new challenge of maintaining effective communication between the health care provider and the patients. Studies have found that although the health professionals are expected to use the Electronic Health Records, very view had training programs for these professionals on how to communicate with the patients in the HER. It is very important therefore that the clinicians should not only be trained on the use of software but also on how the process of communicating with the patients. This will help in removing disconnect and misinterpretation of the information in the system (HM Government, 2011).
The use of HER has also brought about the element of privacy of the patient information. This is important considering the fact that the electronic records can be accessed by all the health professionals in the organization and the other partner hospitals. This is a major challenge since the tools help the health professionals to access collaboration support but the doctors have also the obligations of keeping the information confidential by protecting the patient’s privacy. Another disadvantage of the HER is the fact that computers are faced with the risk of computer crashes. This coupled with the other security breaches from the internets which are on the increase (Griffiths, Mahen ,et al.,2008). The password level used for the Electronic Health Records can be easily hacked. This has caused many systems to move to the two level password system in which the user has ID and password but also are required to make use of the an encrypted key. It has further noted that many computers have built in trail systems that audit and help in the tracking incases of unauthorized access to the system (Johnson, Bulechek, 2011).
Akrldge, J., (2000) Operating room emrs adding wows to cows- healthcare purchasing healthcare purchasing news • www.hpnonline.com
Chamorro et al (2003) Nursing documentation time during implementation of an electronic medical record.
Griffiths P. Jones S, Mahen J et al (2008) State of the Art Metrics for Nursing: A Rapid Appraisal. National Nursing Research Unit, London.
Heiton,J.,Langabeer, J.,DelliFraine, J., & Hsu, C., (2009) Do EHR investments lead to lower staffing levels? HM Government (2011) Making Open Data Real: A Public Consultation.
House of Commons Health Committee (2007) The Bectronic Patient Record, Vol 1. tini-url.com/brw97>’m (Last accessed: October 7 2012.)
Johnson M., Bulechek G et al (2011) NOC and NIC Linkages to NANDA-I and Clinical Conditions: Supporting Critical Reasoning and Quality Care.Third edition.Elsevier Health Sciences.
Kern, et al (2012), Accuracy of Electronically Reported “Meaningful Use” Clinical Quality Measures :A Cross-sectional Study
Michelle, H., Sara, L., Kooienga, T., & Valerie T., (2012) Communication and the electronic health record training: a comparison of three healthcare systems USA PHCSG, British Computer Society
Richards, M.,(2009) Electronic Medical Records: Confidentiality Issues in the Time of HIPAA Research and Practice, American Psychological Association Vol. 40, No. 6, 550–556
Saranto,K., & Kinnunen, U., (November 2008)Evaluating nursing documentation – research designs and methods: systematic review