The electronic health record and nursing practice
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The Electronic Health Record and Nursing Practice. Shawn Stewart, RN, CCM Thomas Edison State College August 24, 2008 Dr Donna Bailey. Purpose. The purpose of this presentation is to provide nurses with a comprehensive understanding of the Electronic Health Record (EHR), including:

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The Electronic Health Record and Nursing Practice

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The Electronic Health Record and Nursing Practice

Shawn Stewart, RN, CCM

Thomas Edison State College

August 24, 2008

Dr Donna Bailey


Purpose

  • The purpose of this presentation is to provide nurses with a comprehensive understanding of the Electronic Health Record (EHR), including:

    • Defining the EHR

    • The Institute of Medicine’s Five Core Competencies

    • Anticipating Clinical Benefits and Obstacles

    • Recommendations for EHR Preparation


What is the EHR?

  • An electronic health record is an instrument that replaces traditional paper documentation with the use of computerized charting systems that interface with other departments.


Value Added for the Patient in Utilizing the EHR

  • Maintains lifetime information about an individual’s healthcare.

  • Provides complete, accurate patient data, regardless of the location of the patient.


Five Core Competencies

  • Delivering Patient-Centered Care

  • Working as Part of an Interdisciplinary Team

  • Practicing Evidence-Based Medicine

  • Focusing on Quality Improvement

  • Using Information Technology


EHR: Transforming Nursing – Clinical Benefits

  • EHR Nursing Tools:

    • Decision Support

    • Clinical Reminders and Alerts

    • Links to helpful professional resources.


EHR: Transforming Nursing – Clinical Benefits

  • Improved Accuracy and Legibility of Documentation

  • Implementation of Standard Nursing Language

  • Increased Accessibility of Medical Record


EHR: Transforming Nursing – Clinical Benefits

  • Increased Time for Bedside Nursing

  • Prompts for Evidence-Based Interventions

  • Eliminate Duplicate Charting


EHR: Transforming Nursing – Clinical Benefits

  • Real-Time Information

  • Ability for Multiple Users to Access Simultaneously

  • Ease of Communication within Multidisciplinary Team


EHR: Transforming Nursing – Clinical Benefits

  • Decreased Time Charting:

    • Automated Population of Vital Signs

    • Check Box Assessments

    • Care Plan Templates


EHR: Transforming Nursing – Clinical Benefits

  • Order Entry:

    • Due to the utilization of electronic order entry accuracy of medication orders will increase. This will result in subsequent increases in quality and patient safety.


Other Clinical Benefits

  • Improved Ability to Track Clinical Outcomes

  • Ease of Gathering and Comparing Statistical Quality Data

  • Enhanced Ability to Perform Timely Data Analysis on a Global Scale for Research Purposes


EHR: Transforming NursingClinical Obstacles

  • Adapting to Change / Resistance

  • Learning Curve

  • Intra-Facility Computer Literacy Initiatives


EHR: Transforming NursingClinical Obstacles

  • System Downtimes

  • Transition Period Frustrations


EHR: Transforming NursingClinical Obstacles

  • System Downtimes

    • There will be times when the EHR is down and the nurse will have to utilize the facility contingency policy. This could cause frustration and resistance to the EHR.


EHR Implementation Barriers

  • System Security Issues

  • Funding Allocation

  • Maintaining Confidentiality

  • Designated Resources:

    • Overhaul of Policies and Procedures

    • Development of Implementation Plan

    • Staff Education and Training


Recommendations to Prepare for the EHR

  • Develop a task force or committee within your organization to identify anticipated barriers.

  • Utilize this team to create action plans specific to your team’s needs in preparing for implementation of the EHR.


Recommendations to Prepare for the EHR

  • Utilize forums such as Town Hall Meetings with administration & departmental meetings to inquire about the facility’s plan for an EHR.

  • Is there a nursing informatics position within your organization? Find out what resources are available.


Recommendations to Prepare for the EHR

  • Above all – Anticipate the direction in which documentation is changing. Be sure that you are ready!

  • Individual Skill Development: Taking a Computer Class or Learning to Type.


References

  • American Nurses Association (2008). Nursing informatics: Scope and standards of practice. Retrieved August 18, 2008, from http://nursingworld.org/books/pdesecr.cfm?CNum=3.

  • Glaser, J. (2007, October). The electronic health record: A digital divide? Retrieved August 21, 2008, from CINAHL database.

  • Health Professions Education: A Bridge to Quality. (n.d.). Retrieved August 23, 2008, from http://www.nap.edu/openbook.php?record_id=10681&page=1.

  • Pomerleau, M. (2008, April/May 2008). Electronic health record: Are you ready for the next step? Nursing for Women’s Health, 12(2), 151-156.


References

  • Selenke, J. (2007, December). EHR Bliss. Health Management Technology, 38-39.

  • Thede, L.Q. (2003). Informatics and nursing opportunities & challenges (2nd ed.). Philadelphia, PA: Lippincott Williams & Wilkins.


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