The Electronic Health Record (EHR) created and maintained by the computer system will provide us with a comprehensive analysis of the patient. As the patient enters our system, we will be able to enter relevant data such as current and previous medical histories, allergies and medications. As additional studies and tests are conducted, they will become part of the patient’s medical record and will be available for review and comparison by any physician authorized to access our system. This allows a better review of the chart because it is organized by the categories established by the program itself (history and physical, radiology results, lab results, etc). The computerized physician order entry (CPOE) component provides additional tools for the physician to utilize when placing orders and provides a layer or safety for the patient. As physicians place orders, the clinical decision support (CDS) component of the system can assist the provider in making decisions by providing the most current information about a particular drug ordered to include potential drug interactions or advising when a drug may cause an allergic reaction based on patient sensitivity. It can also provide the physician with the most recent test results (labs, radiology) in order to trend results and to prevent unnecessary repeat testing. The components of CDS, CPOE and health information exchange (HIE) are only a few of the aspects of the computer system that meet the “meaningful use” requirements of HIGHTECH.
The CPOE component allows for clear and complete instructions to other healthcare disciplines. The issue of poor penmanship is no longer an issue. Nursing, nutrition, lab, etc. can access the patient record and understand the physician order entries. As the physician places orders, the CDS component will prompt the physician based on the orderset (pneumonia, STEMI, chest pain, etc.) chosen to ensure all relevant areas of patient treatments/tests are addressed. These prompts assist the physician by confirming all relevant areas are evaluated and allows for more comprehensive testing resulting in a better means of evaluating patient diagnosis and treatment. This can also assist in assuring that all core measures are met, should this be relevant to patient care prior to discharge.
It is imperative that nursing be included in the decision making process of choosing an appropriate CMS. Although physicians will be placing orders, evaluating results of tests, and making clinical decisions based on the information gleaned from the hospital’s computer system, it must be understood that the physician component is only one portion of the overall purpose of computer management. Furthermore, it must be remembered that nurses have the responsibility of ongoing bedside patient care. This ongoing responsibility includes obtaining admission history, home medications, immunization history, safety...