Medical Record Keeping
Abstract
This academic investigation of the pros and cons of the electronic medical record keeping technology required in hospitals across the United States by 2014 as called for by the U.S. Health and Human Services Department provides documentation of more pros than negatives. The ability for nurses, physicians, and other healthcare clinicians collaborating through technology for better and faster documentation of patient status, for evaluation, and differentiation of therapies as needed proves this a valuable medical tool. The negatives include some of the technological systems need revamping for such inclusion as standardized nursing language in the software. Other negatives looked at the time nurses took finding computers and the time it took to enter the information. Other recommendations suggest further research on the overall benefit to the patient care.
technology, medical, records, nursing
Technology in Healthcare:
The Pros and Cons of Electronic Medical Record Keeping
Introduction
The 21st century focus on technology requires understanding the pros and cons of electronic medical record (EMR) keeping and its connection to nursing documentation. This academic exercise provides the relevance of EMR use to the profession of nursing. In addition, discussion on the pros and cons provide realistic characteristics of this technical application for medical professionals focus on patient safety and care. The use of EMR connection to the protocols of both the Texas Nursing Board as well as the American Nursing Association standards provide further validation of the importance of this technology for nursing professionals care of patients for assessment and necessary differentiation of therapy in collaboration with physicians.
Relevance to the Profession of Nursing
The expectations of physicians of the quality, relevance, and accuracy of nursing documentation for better collaboration between the two for optimum patient care looks at the use of EMR applications as a standard procedure. The intent of using EMR looks at nursing input providing greater clarity as well as additional pertinent information not available, using the typical physician checklist when detailed patient intervention data and assessments. Consequently, according to Seeley (2009), '' Health care leaders are compelled to understand how they can incorporate technology'' into better safety and care of patients (p. 329).
Pros of Using the EMR
Use of EMRs enables nursing professionals greater ability documenting patient data with important detail, directness, and as importantly, in a timely manner (Green & Thomas, 2008, p. 225). According to the Texas Board of Nursing (TBN) Position Statement both a critical and fourth step in the nursing process remains evaluation. Use of the EMR for participation in the critical evaluation of the patient prognosis and status for reporting this data underscores the pragmatic use of the EMR providing this collaborative information to the physician. The reporting process using the EMR provided the nursing professional proactive measures for rapid engagement of the physician when patient therapy alterations occur (2013)
Texas Board of Nursing (Pros)
Further, use of the EMR by nursing professions in applying the evaluation process for identifying and reporting any alterations in patient reactions to the remedial interventions converge for comparison to the existing prescribed and expected results. Use of the EMR aligned to the Texas Board of Nursing Position Statement on evaluation, provides the means for the nursing professional contributing to this ongoing phase of patient care and treatment. In addition, integrating use of the EMR provides the nursing professional patient evaluation more rapid recommendations for physician perusal in the event modifications arise within the existing therapy promoting facilitation of continuity of patient care (TBN, 2013). According to Green and Thomas (2008), the EMR provides opportunity for quicker, less likelihood of error for the physician and nurse delivering quality patient care. Looking at the future of EMR use in the medical profession demands the interaction of physician and nurse professional working with the technicians developing the kind of EMR systems needed in their clinic or hospital (p. 240).
Cons of Using the EMR
Confined to a specific study of the use of EMR in a perinatal setting, the outcomes of the outcome of the trial of using the EMR gleaned data resulting from a survey of feedback from the participating nursing staff. The findings, according to Chao and Goldbort (2012) includes assessing the only difference between the use of the EMR during a 14-hour shift in the labor and delivery activities of nurses was charting their activities and more face-to-face interactions involving patient care and other clinicians. The assessment proved no significant influence of use of the EMR affecting the nurse work related activities, or his or her workload (p. 604).
Use of the EMR according to the Conrad et al (2011) study among ambulatory care nurse practitioners and use of standardized nursing language (SNL) show some peers continue not using the SNL in documenting patient care. The barriers connected to the effectiveness of the EMR include the time needed to locate an available computer, the time to enter the data, and the fact there is no reimbursement to the nursing staff using the technology (p. 443).
In response to the 2014 deadline by the USHHSD of all national hospitals use of EMR systems, Kelly et al (2011) provide describe further insights to some of the remaining barriers aligned to the EMR use (p. 159). According to Donabedian (1980), the major findings show existing gaps in research gaps remain connected with quality characteristics of the process, the structure, and the outcomes (as cited by Kelly et al, 2011, p. 159). Further, according to Kelly et al (2011), it remains an unknown, as the exact amount of improvement of patient care actually exists when nurses use electronic documentation. In addition, from these studies the nurse attitudes according to the empirical methodology of data gathering, about EMR along with his/her perceptions connected to their use in the hospital environment, show extensive information as a starting point for further studies (p. 159).
Additional negative aspects of the use of the EMR according to Darbyshire (2004) and Likourezos et al (2004) reveal how nurse perception of the use of the EMR brought them frustrations because the EMR interfered with him/her providing patients the desired level of individualized care they focus providing patients (as cited by Kelly et al, p. 156). Timmons (2003) adds finding a computer to enter EMR information too often becomes counterproductive (as cited by Kelly et al., p. 156), and Darbyshire (2004) explains complexities of remembering passwords and computers running slow also deter timely record keeping of the care of patients (as cited by Kelly et al., 2011, p. 156) add to the undesirable side effects. Kelly et al (2011) offer the undesirable aspects of the use of EMR is the fact nurses may focus too much of their time using the EMR system possibly affecting their time needed for taking care of his or her patients (p. 156). As a result, of the Kelly et al (2011) research they explain too little documentation of the effectiveness of EMR use 'connected to delivering quality patient care in hospitals. Consequently, as concluded by Kelly et al (2011), only with understanding nursing interaction documenting patient care on paper can the effectiveness of the EMR format be maximized (p. 159).
Roles and Responsibilities for the Profession of Nursing
ANA Standards
In line, with the American Nursing Association (ANA), Standards of Professional Nursing Practice Standards 1, 2, 3, and 5 clearly align to the benefits of using the EMR. Assessment requires collecting details of the patient demographics connected to their medical needs. With the assessment, the nurse provides the needed diagnosis for doctor collaboration on treating the patient. In this process, the nurse identifies desired outcomes of the individualized patient therapy for implementation of care for the patient in connection with the use of EMR. In doing so, the registered nurse (RN) complies with the collection of comprehensive data on the patient for collaboration with the physician (2013). According to the U.S. Department of Health and Human Services (USDHHS) (2010), "hospitals across the United States are expected to become meaningful users of electronic health records by 2014 (as cited by Kelly, Brandon, & Docherty, 2011, p. 155). The implications of this protocol look at the roles and responsibilities of the nursing professional in conjunction with the use of the EMR for interventions in patient care needs.
EMR Use for Assessment and Intervention Action
Exemplifying the application of EMR assessment leading to intervention actions in the care of a patient looks at the improved screening and diagnosis of childhood obesity. Actions including interventions by the nursing professional remain critical for three reasons in this process. Primary in diagnosing childhood obesity looks at improving the outcomes once recognized with evidence-based intervention of counsel to both the patient and family. Counsel intervention includes providing printed material for patients directed for individualizing a planned care for counter measures to address the weight issue (Savinon et al, 2012, p. 463).
A second intervention in addressing EMR-diagnosis related childhood obesity, according to Savinon et al, 2012, calls for "a follow-up appointment" for discussing ''healthy lifestyle changes'' implemented per the ''evidence based'' diagnosis as well as the intervention for this plan of action. With the third intervention, further encouragement of the parent and child urges their participation in scheduling monthly sessions with the primary health care provider for as long as 6 months to monitor and provide further interventions as required in the overall plan of action addressing the obesity issue. These monthly meetings encourage motivating the patient and family with problem identification, how to develop consistencies in their behavior connected with their values and beliefs. 'In this manner, customizing the ''Healthy Option Visit'' fitting the individual need of the patient and family support provides ease of access of resources and other tools aligned to interaction with caring for the patient needs with the family and the patient incorporating the evidence-based prescribed recommendations (p. 463).
Summary
The findings of this academic investigation of nursing professionals' use of EMRs for collaboration with physicians proves the pros outweigh the cons since written record keeping versus the electronic reveal less errors with the latter. The EMR use in clinics and hospitals already earmarked by the USDHHS for across the nation implementation by 2014 emphasizes the support by both the ANA and TBN protocols. The logical underpinning of one barrier to using the EMR is the lack of this technology in facilities. Use of SNL remains fundamental in the professional field and therefore EMR systems not having the SNL program stands for unacceptable conditions for using the EMR. Other barriers, the literature reveals connects with the lack of familiarity of SNL among some personnel. The overall picture here provides a positive look at the future of EMR use in the medical field for all professionals involved.
Reflection
I value this academic exercise as a nurse professional because of the positive aspects it provides in using EMR for patient safety and care, and as importantly, collaboration with physicians and other clinicians in this process. This enhances confidence in my nursing abilities I seek developing. As another tool for patient care and safety but also I see how the EMR increases opportunity gaining trust of the patient toward their earliest recovery. The feedback of the participating nurses holds the most prominent draw from a personal perspective because this involved qualitative face-to-face interviews and survey responses. The conclusions of Estrada et al (2012) concur with my overall personal feelings I found invaluable from participating in this academic experience about EMRs. They write the expectation of the EMR giving nursing professionals better assessment of patient needs and provide them that kind of care (p. 86).
References
American Nursing Association. (2013). Standards of Professional Nursing Practice. Ferris State University. Retrieved from http://www.ferris.edu/HTMLS/colleges/alliedhe/Nursing/Standards-of-Professional-Nursing-Practice.htm
Chao, C. A., & Goldbort, J. (2012). Lessons Learned from Implementation of a Perinatal Documentation System. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 41.
Conrad, D., Hanson, P. A., Hesenau, & Stocker-Schneider, J. (2012). Identifying the Barriers to Use Standardized Nursing Language in the Electronic Health Record by the Ambulatory Care Nurse Practitioner. Journal of American Academy of Nurse Practitioners. 24. 443-451.
Estrada, N. A., & Dunn, C. R. (2012). Standardized Nursing Diagnosis in an Electronic Health Record: Nursing Survey Results. International Journal of Nursing Knowledge. 23(2)
Green, S. D., & Thomas, J.D. (2008). Interdisciplinary Collaboration and the Electronic Medical Record. Pediatric Nursing. 34(3).
Kelly, T. F., Brandon, D. H., & Docherty, S. L. (2011). Electronic Nursing Documentation as a Strategy to Improve Quality of Patient Care. Journal of Nursing Scholarship. 43(2), 154-162
Savinon, C., Taylor, J. S., Canty-Mitchell, J., & Blood-Seigfried, J. (2012). Childhood Obesity: Can Electronic Medical Records Customized with Clinical Guidelines Improve Screening and Diagnosis? Journal of the American Academy of Nurse Practitioners. 24. 463-471.
Seeley, B.E. (2009). Introducing a Computer-Based Electronic Record: Perceptions of Clinicians. Urilogical Nursing. 29(5)
Texas Board of Nursing. (2013). Position Statement. Retrieved from
http://www.bon.texas.gov/practice/position.html#15.28
