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NURS 3510 Clinical Foundations of Nursing Practice (EHR) Sherpath Latest Updated Study Guide
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NURS 3510 Clinical Foundations of Nursing Practice (EHR) Sherpath Latest Updated Study Guide
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lOMoAR cPSD| 42147428NURS 3510 Clinical Foundations
of Nursing Practice (EHR)
Sherpath Latest Updated Study
Guide
, lOMoAR cPSD| 42147428
Introduction
Health care documentation is patient information (data) documented on paper or electronically
generated that describes the patient’s health, care, and services provided. The primary purpose of
health care documentation and record-keeping systems is facilitation of information flow that
supports the continuity, quality, and safety of patient care. Understanding the critical components
of health care documentation and standards related to documentation contributes to quality
patient care and positive health outcomes. Today, patient health records have changed. Instead of
being paper charts, they have become electronic health records, meaning out with the paper and
in with the computer!
Upon completion of this lesson, you will be able to:
• Discuss nursing documentation in the electronic health record
Overview
The electronic health record (EHR), a safe, secure, password-protected system, is the key to
patient data and information essential for patient care and nursing practice. It is the major
communication tool among health care providers, key hospital personnel, and often the patient.
Patient information is protected by assignment of individual passwords that should never be
shared. It is a legal source of information and is required to be complete, up-to-date, accessible,
and accurate. These key attributes allow health care providers and patients to make appropriate
clinical decisions.
Defining the EHR
The EHR is a digital version of the patient’s chart. It provides real-time information about the
patient’s health and is continuously updated to ensure that the right information is provided to
the right person at the right time. The National Library of Medicine assists in the development
and management of standards related to the EHR. Nursing’s approach to the EHR is to
understand the transition from paper to computer as a means of creating an environment where
patient-related data and information are accessible, accurate, and immediate to foster decision-
making for nursing and patient care.
Contents of the HR
The EHR contains specific information about the patient’s medical history, treatment plans,
diagnostic test results, current and previous health diagnoses, allergies, and medications. It is an
individualized “map” of the patient to plan appropriate care.
Improving Care with the Electronic Health Record
, lOMoAR cPSD| 42147428
The EHR provides essential patient information to guide health care providers for effective care
planning. It brings together nursing documentation, health care provider documentation, allied
health professional information, medications, and diagnostic testing.
Patient- Method Example
Related Needs
Convenience Remote access to Clinicians can access patient-related information from
patient records any computer on the EHR system.
Enhanced Point-of-care The nurse is caring for a patient with diabetes who
decision information appears diaphoretic while lying in bed. A rapid blood
support sugar test can provide almost immediate results that
would allow the nurse to take action.
System Connectivity with all A patient is having difficulty breathing. It was noted
interface hospital systems that the patient had a chest x-ray and laboratory work
including laboratory, earlier in the day. The nurse checks the computer and
radiology, and finds that the laboratory results show an increased
pharmacy white blood cell count, and the x-ray indicates left
lower-lobe pneumonia. The nurse contacts the
provider for medication prescriptions.
Patient Use of handheld Patients in the hospital are given electronic tablets
involvement devices for patient when admitted to the unit. The patient is able to
in care care follow his or her care and test results on a near–real-
time basis, allowing the nurse to provide patient
education and assist the patient in understanding the
results.
Discharge System integration The nurse is discharging a patient with multiple needs.
planning The nurse is able to instruct the patient on how to
access the health care provider using a patient portal,
use e-prescriptions to facilitate medications, and
access electronic copies of discharge prescriptions
through an email process, eliminating the need for the
patient to have multiple sheets of paper (that can be
lost) and facilitating patient care needs, information,
and access.
Benefits and Challenges of EHR Use
Adoption and use of an EHR system can yield positive results in efficiency and patient care
safety, but its use is not without challenges.
Benefits
• Enhances communication among all members of the health care team
• Supports administrative processes with more efficient and timely data extraction for
scheduling, billing, and claims management
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