Documentation, Emr, and Patient Safety - Special Academic Support

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Three major elements of the electronic medical record (EMR) include patient call log, prescription management system, and patient management (Kelley, 2016). The patient management component is important in patient registration, transfer, admission, and discharge from a hospital. It affects safety measures if improperly conducted or used to generate information that lacks integrity. Correct documentation prevents errors by ensuring that patients give correct medical histories and other information that determines their length of stay in the hospital (Skolnik, 2010). Incorrect documentation can cause errors such as wrong diagnosis and incorrect prescription. A patient call log documents conversations between healthcare providers and patients (Kelley, 2016). It affects safety measures in case of misinterpretation of conversations or if a patient provides misleading information. Improper documentation causes errors such as wrong medication and inadequate monitoring and follow-up (Skolnik, 2010). A prescription management system ensures that physicians make correct prescriptions and consider critical patient information such as allergies and medications a patient could be currently taking (Masters, 2015). The prescription management system affects safety measures by increasing a patients length of stay in hospital and compromising the effectiveness of strategies to reduce medical errors. Proper documentation reduces errors by promoting proper order communication, product labeling, dispensing, and administration. Moreover, it ensures that physicians give correct prescriptions to patients based on the diagnosis done (Kelley, 2016). In addition, it allows physicians to consider a patients allergic reactions to certain drugs. Improper documentation increases errors such as wrong medication, wrong drug administration, and inaccurate drug labeling.

The main role that nurses play in the use of EMR is the improvement of the reliability, accuracy, and integrity of information through timely documentation (Masters, 2015). The information contained in EMR systems must be accurate and efficacious in the enhancement of patient safety and evaluation of care quality. It is the responsibility of nurses to enter patient information into electronic systems and conduct regular reviews in order to ensure that it is accurate and up-to-date (Skolnik, 2010). For example, they can enter information regarding the medical histories of patients using physician-approved templates in order to increase the accuracy of the data provided. EMR are most effective in improving patient care when physicians and nurses work together and shoulder some responsibility. It is the duty of nurses to prevent medical errors that often occur in prescribing, transcribing, dispensing, and administering medications (Skolnik, 2010). Nurses help physicians use EMR by specifying interventions that need to be applied in order to achieve certain desired outcomes (Masters, 2015). Nurses provide safe client care by supplying physicians with correct information regarding aspects of patients health situations such as medical history, other medical conditions, medications administered, and the presence of allergies. Nurses should record the care provided to individual patients as well as the patient responses and the outcomes of treatment (Skolnik, 2010). Appropriate timing is important especially in the case of emergencies that require quick attention from physicians. Accurate documentation enhances the safety of medical processes that include diagnosis, prescription, and administration of medications.

References

Kelley, T. (2016). Electronic health records for quality nursing and health care. Lancaster, PA: DEStech Publications.

Masters, K. (2015). Role development in professional nursing practice (4th ed). Burlington, MA: Jones & Bartlett Publishers.

Skolnik, N. S. (2010). Electronic medical records: A practical guide for primary care. New York, NY: Springer Science & Business Media.

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