Kathleen M Lepley
April 11, 2011
Electronic Patient Charting Implementation
In today’s ever -changing health care system there is a need for constant updates but also thorough accuracy. The way these pieces of information are assembled and implemented is vital to the survival of any health care organization. The addition of Electronic Patient Record Charting (EPR) will provide for continued patient confidentiality and charting accuracy. In addition, it is a necessary step in the direction of Electronic Patient Records. The goal of the implementation of the EPR is to enhance health care delivery from the nursing spectrum and allow for improved charting accuracy, decrease errors, and provide thorough documentation.
Nurses are an essential part of today’s health care system. Pt care is the core of all health care organizations. Many institutions have moved focus to electronic charting. One of the most important aspects of this is patient focused charting. It is necessary for the organization to implement this change and move forward with a proposal for this change as we focus on the information technology vital today for our health care system. In addition, we recognize that there will be organizational and individual barriers that will occur. We will look at proposed factors and a proposed theory model that influence the change to EPR and show how it will benefit this institution positively. As we move forward and to this type of patient documentation, it is to focus on high quality patient care and enhance patient confidentiality.
In addition, staff understanding and comprehension is proposed so that all staff understands that a move toward this type of patient documentation is necessary to the continued success of this institution and patient- centered focus. The theoretical model presented centers on this core change to electronic charting. The proposed model will allow staff to see how the change will become success and implemented through a series of steps and support teams. Finally development of external and internal resources are presented .These resources will be readily available and help to support this change initiative through their expertise and guidance. The nursing staff will have seminars and support groups and training sessions so that they will be able to deliver the highest quality patient -care on a 24 hour continuum.
The EPR is a new challenge. Change to any type of new documentation can be foreign to anyone on staff who are uncomfortable with computers and accustomed to charting patient documentation a certain way for many years. EPR is essential to the continued safety and critical to the aspect of high quality patient care and financial reimbursement. Improving patient documentation will enhance necessary standards set by The Joint Commission of Accreditation of Healthcare Organizations, (JCAHO). This documentation standard will improve quality of patient care and patient focused documentation. ( Nehm &Poston 2000, Kossman & Schneidenhelm, 2008.)
In addition, specific detail and legibility and immediate patient wishes are readily available by allowing the nursing staff to be more attentive to patient care because the new EPR will allow for improved time management and thorough documentation. The major reason for moving toward this type of documentation will be so that this institution can focus on high quality patient care, by decreasing charting errors and legibility issues that the current charting system entails. Providing a chart that is accurate will set documentation standards of detailed charting are required by JCAHO and readily available to all users who are allowed to access the patient chart. The EPR will give patients a voice in their own care, and a tool necessary...