Electronic Medical Records and Charting
Today’s healthcare is changing, and more hospitals are commencing to go paperless using computers for both medical records and charting. Computers are widely accepted, in personal and professional settings. It is an essential requirement for computer literacy. Numerous advances in technology during the past decade require that nurses not only be knowledgeable in nursing skills but also to become educated in computer technology. While electronic medical records (EMR’s) and charting can be an effective time management tool, some questions have been asked on how exactly this will impact the role and process of nursing, and the ultimate effects on patient safety and confidentiality. In order to investigate these topics, I will be addressing the individual aspects of EMR’s that nurse’s use every day, how they affect collaborative care, and the impact they have on the nursing role.
In the Emergency Department at General Leonard Wood Army Community Hospital (GLWACH) manual paper charting is still used for charting most of the patient care that is per-formed; the exception would be any laboratory studies needed and any kind of radiology proce-dures that must be done. These orders are then put into the computer system, most often by the nurses. I had an opportunity to observe both positive and negative indications during my 72 hour preceptorship at the General Leonard Wood Army Community Hospital. Some of the positive of having EMR’s and electronic charting are that: they are pass code protected, allow access to in-formation quickly, legibility and organization aspects, efficiency of time, and allow for easy transfer of data which minimizes errors. If a patient comes in by ambulance, and is unconscious the medical staff can type the patients name into the computer and could pull up any pervious medical history they might have on that patient This can alleviate many of the questions the doc-tors and nurses would have about the patient such as, any drug allergies, any chronic diseases, and the next of kin information. Some negative indications when using EMR’s could be: power outages and or computer glitches, potential privacy threats, and some believe that it may lead to depersonalized patient care.
EMR’s and charting are becoming a bigger part of an ever changing aspect in the world of healthcare and should be used more in the Emergency Department at GLWACH and in all Emergency Departments across the nation. With further research looking into ways to fix any glitches and provide continued upgrade of systems, EMR’s have the potential to reduce health care costs, improve efficiency, and to enhance the quality of care and patient safety that is provided by the nurse and the rest of the medical staff in the Emergency Department. At this time GLWACH Emergency Department does use paper charting but the paper charts do get scanned and uploaded onto a computerized system to be made part of their permanent EMR.