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: - PowerPoint PPT PresentationTRANSCRIPT
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Shawn Stewart, RN, CCMThomas Edison State College
August 24, 2008Dr Donna Bailey
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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
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An electronic health record is an instrument that replaces traditional paper documentation with the use of computerized charting systems that interface with other departments.
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Maintains lifetime information about an individual’s healthcare.
Provides complete, accurate patient data, regardless of the location of the patient.
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Delivering Patient-Centered Care
Working as Part of an Interdisciplinary Team
Practicing Evidence-Based Medicine
Focusing on Quality Improvement
Using Information Technology
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EHR Nursing Tools:
Decision Support
Clinical Reminders and Alerts
Links to helpful professional resources.
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Improved Accuracy and Legibility of Documentation
Implementation of Standard Nursing Language
Increased Accessibility of Medical Record
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Increased Time for Bedside Nursing
Prompts for Evidence-Based Interventions
Eliminate Duplicate Charting
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Real-Time Information
Ability for Multiple Users to Access Simultaneously
Ease of Communication within Multidisciplinary Team
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Decreased Time Charting:Automated Population of Vital SignsCheck Box AssessmentsCare Plan Templates
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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.
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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
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Adapting to Change / Resistance
Learning Curve
Intra-Facility Computer Literacy Initiatives
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System Downtimes
Transition Period Frustrations
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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.
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System Security Issues
Funding Allocation
Maintaining Confidentiality
Designated Resources:Overhaul of Policies and Procedures
Development of Implementation Plan
Staff Education and Training
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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.
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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.
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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.
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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.
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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.