Sample Nursing Essays on Health Care Charting Systems

A health care or medical chart refers to a record containing key clinical data and medical history belonging to a patient. The data entails demographics, diagnoses, vital signs, treatment plans, medications, immunization dates, radiology images, and laboratory results among others. A medical chart also comprises of crucial medical notes made by a physician, nurse, or any other person forming part of the patient’s healthcare team. A complete and accurate health care charting system ensures systematic and proper documentation of the diagnosis, treatment, care, and medical history of a patient. Ideally, with a good health care charting system, a clinician should be able to understand everything that has previously occurred to a patient allowing the diagnosis of a patient’s current disease state. A specific technology falling under health care charting systems is the electronic medical record (EMR).

Explanation of The Technology, History, and Integration

Electronic medical record (EMR) refers to a digital version of paper charts contained in clinics, hospitals, and clinician offices. EMRs primarily contain information that is collected by and for clinicians and are used for treatment and diagnosis purposes. Additionally, they were introduced as replacements for paper medical records that have been around for several years now (Bates, Ebell, Gotlieb, Zapp, & Mullins, 2003). A few years ago, it was common for clinicians and other staff forming part of the health care team to document information on facility-based paper charts. Nurses had the responsibility of memorizing the protocols of circling assessment findings and making records of vital signs in dots and arrows. Nevertheless, it was difficult for these professionals to find a black ink-pen for recording purposes since other colors were not allowed. Nurses also had to handwrite care plans and shift notes; thus, errors were common in documents (Bates, Ebell, Gotlieb, Zapp, & Mullins, 2003). EMRs were introduced and integrated into the health care system to help with the standardization of documentation, prevention of errors, promotion of concise charting, and long-term storage of medical records.

EMRs help in facilitating work flow in health care organizations as well as improving patient safety and overall quality of care offered to patients. The importance of EMRs notwithstanding, the integration of the technology in many countries, including the United States, is relatively low. According to recent surveys, roughly 4 percent of physicians handling outpatient care use complete and fully operational EMR systems. The surveys further indicate that around 13 percent of physicians handling outpatient care have basic EMRs. The integration of EMRs into the healthcare system presently faces significant barriers. One of the major barriers is the high capital cost for small practices that, in turn, receive an insufficient return for investing in the technology (Miller & Sim, 2004). Concerns that EMRs will become obsolete in the coming years is another barrier to the technology’s integration into the healthcare system presently. Other obstacles to the technology’s adoption include the lack of skilled resources enabling implementation and support as well as concerns that surround negative impacts of the technology in healthcare facilities.

Benefits of the Technology to Organizations and Patient Care

Despite the low adoption of EMR technology, it has numerous benefits to organizations and patient care. For organizations, one of the benefits of EMR is standardization evident in how the technology has improved standard record-keeping (Androus, 2019). Besides, the technology improves accessibility since it enables health care team members to have easy access to medical records. In the same vein, EMR technology allows effortless retrieval of records between different healthcare organizations (Androus, 2019). Another significant benefit of EMR technology to healthcare organizations is the reduction of errors. EMR comprises of computerized physician ordering that plays a key role in reducing errors that are related to misinterpreted handwriting and transcription.

For patients, one of the major benefits of EMR technology is improved privacy and security. The use of paper records threatens patients’ privacy and security if more hands are involved (Androus, 2019). Additionally, sending paper charts outside healthcare facilities is often accompanied by an increased risk of privacy breach. EMR technology averts these risks since only appropriate employees are allowed access to specific parts of the EMR. In most cases, flags are set up in the event of inappropriate access to a record. Another benefit of the innovation to patients is improved efficiency. Once integrated into the healthcare system, EMRs tend to enable fast documentation, thus benefiting patients who require fast diagnosis and treatment. For instance, with the help of EMR, it is possible for health care professionals to perform EKG and have information on the same uploaded to a record in the shortest time possible. The information can then be pulled up and advise offered to the patient in a short time as well resulting in improved care outcomes.

EMR is an example of a healthcare charting system. EMR was introduced as a replacement for paper medical records. The technology has numerous benefits to healthcare organizations and patients’ care. Some of the benefits include standardization, improved accessibility, reduction of errors, improved privacy and security for patients, and improved efficiency.

 

 

References

Androus, A. B. (2019, November 10). What are some pros and cons of using Electronic Charting (EMR)? Retrieved from https://www.registerednursing.org/answers/pros-cons-using-electronic-charting/

Bates, D. W., Ebell, M., Gotlieb, E., Zapp, J., & Mullins, H. C. (2003). A proposal for electronic medical records in US primary care. Journal of the American Medical Informatics Association10(1), 1-10. Retrieved from https://academic.oup.com/jamia/article/10/1/1/815900

Miller, R. H., & Sim, I. (2004). Physicians’ use of electronic medical records: barriers and solutions. Health Affairs23(2), 116-126. Retrieved from https://www.healthaffairs.org/doi/full/10.1377/hlthaff.23.2.116