Electronic Medical Record, Reaction Paper Example

Introduction

The assessment of patients is typically focused on a specific problem that is bothering the patient and for which her or she has entered the facility for evaluation and treatment. This process supports the development of new assessment techniques and or evaluation tools, depending on the frequency of the patient’s visits, and their entry into the electronic health record. This also requires nurses to possess sufficient knowledge of the software system that is used, as well as the patient’s health status, in order to achieve accuracy in entering information into the electronic health record (Schiff & Bates, 2010). From this perspective, it is necessary to address the findings associated with the patient as best as possible in order to prevent diagnostic and treatment errors in patients (Schiff & Bates, 2010).

Analysis

Recording patient histories and physical assessment findings are based upon existing information listed in the electronic health record, coupled with new findings that the nurse identifies during the assessment, as well as the information that the patient provides. These factors are important because they require full documentation in the record; however, there must be some degree of flexibility in how patient-related notes are entered into the system (Rosenbloom et.al, 2011). This process also requires an understanding of any underlying conditions that could be involved in the assessment, such as behavioral and/or psychosocial assessments, as all of these could pose a risk to patients that requires further care and attention (Rosenbloom et.al, 2011).

The electronic health record must serve as the portal for disseminating all patient findings so that other patients are able to view them in a timely manner (Wrenn et.al, 2010). At the same time, redundant information is not welcome into the electronic health record because it may lead to diagnostic or treatment concerns (Wrenn et.al, 2010). These issues are relevant because they convey the importance of developing standardized methods to record assessment findings and evaluating patient histories that are found in the electronic health record. These factors are instrumental in modern healthcare practice and tend to tie all of the elements together in order to have a greater impact patient care quality (Wrenn et.al, 2010).

Electronic health records have a significant impact on maintaining consistency in healthcare records and in developing new strategies for growth that will encourage the development of new approaches to improve practice settings. However, the potential exists for miscommunication in some cases involving electronic health records because nurses may distort knowledge in these records, which may lead to poor communication with other nurses and with patients (Lown & Rodriguez, 2012). Therefore, these aspects demonstrate the importance of developing new approaches to alleviate miscommunication so that patient care is not compromised in these settings (Lown & Rodriguez, 2012). Most importantly, the electronic health record must list the present findings clearly and concisely, and also determine a diagnosis and provide a course of treatment as necessary that will have a positive impact on patient care outcomes and on communication in the patient care setting that is essential to the success of the diagnosis and treatment plan (Lown & Rodriguez, 2012).

Conclusion

Patient assessments are entered into electronic health records to provide a single location where records are available. However, these records must demonstrate an important understanding of accuracy in charting and in recording assessment, diagnostic, and patient information in an effective manner. This process supports the development of new approaches that will be effective in providing patients with much-needed care and treatment in a safe and comforting environment.

References

Lown, B. A., & Rodriguez, D. (2012). Commentary: Lost in translation? How electronic health records structure communication, relationships, and meaning. Academic Medicine, 87(4), 392-394.

Rosenbloom, S. T., Denny, J. C., Xu, H., Lorenzi, N., Stead, W. W., & Johnson, K. B. (2011). Data from clinical notes: a perspective on the tension between structure and flexible documentation. Journal of the American Medical Informatics Association, 18(2), 181-186.

Schiff, G. D., & Bates, D. W. (2010). Can electronic clinical documentation help prevent diagnostic errors?. New England Journal of Medicine, 362(12), 1066-1069.

Wrenn, J. O., Stein, D. M., Bakken, S., & Stetson, P. D. (2010). Quantifying clinical narrative redundancy in an electronic health record. Journal of the American Medical Informatics Association, 17(1), 49-53.