Report Prepared By:
Gary Holt RN
Director of Nursing Informatics.
Pg. #1 TOPIC A: EMR SYSTEMS AND PATIENT QAULITY CARE OUTCOMES. EMR stands for “Electronic Medical Record”. This section of the report is to explain to you the benefits to improving the quality of patient care we can provide to our patients by utilizing the EMR system. As we all know our number one goal is positive patient outcomes and safety of our patients. Part of this is always looking for the latest technologies and systems available in which to achieve this and to continue to improve positive patient outcomes. So you may ask how these positive outcomes would be achieved through utilization of an EMR software system. The first topic I would like to make mention of which is crucial to all of us in direct patient care is, TIME MANAGEMENT. I have capitalized this in bold print to emphasize its importance. The EMR system in comparison to our current hand written system with the Physical medical record will cut down on documentation time immensely. How you may ask? The first main point I would like to make is with use of the EMR system all disciplines of the healthcare team will have the ability to access the patient’s medical record at the same time to review and enter any information for the care of the patient. You will no longer need to wait for a physical medical record in which you have to track down as well as wait to use if someone else is using it or if the patient is off the unit for a test.. And you will no longer have to wait to hand write a note, order, or assessment as you will be able to log in to the EMR system to enter and review this information. Once you have entered and saved this information it will be available almost immediately for not only you but for everyone else reviewing that patients information to see as well. And what this will do as a result is cut down on the time previously needed with a hand written chart being shared. This in turn will create much more time actually taking care of Pg. #2 Continued: the patients to better assess, provide more frequent communication with them as well amongst us as a multi-disciplinary team. The second main point I would like to make is in regards to potential misinterpretations or medical mistakes as the result of illegible or messy handwriting. As we all know the amount of documentation we have to provide for our patients is more and more every year. The reasons as we all know are mainly lawsuit and medical malpractice driven in conjunction with more and more state as well as federal rules and regulations. Having progress notes, assessments, and consults, diagnostic imaging studies and most importantly M.D. orders in a typed easy to read format will cut down on these potential errors drastically by being able to read and interpret them without question. Also, by being able to read the information that is now typed with ease; if there is a further need of clarification to be questioned, it will be recognized and addressed much quicker than previously. TOPIC B: THE IMPORTANCE OF NURSING INVOLVEMENT IN THE PLANNING, CHOICE, AND IMPLEMENTATION OF THE EMR SYSTEM. As we all know Nurses are on the front lines of patient care. Much of their job requires documentation and communication. This would include their Nursing assessments, progress notes, taking MD orders, documenting medications and treatment administration they have completed. In addition, to do this they are constantly reviewing patient data from imaging studies, laboratory studies, consults and evaluations just to name a few responsibilities. This is why it is crucial that Nurses have some of the greatest input and involvement for the choice of EMR systems and the way it is implemented in a Healthcare setting. They need to evaluate how the software system will work with the documentation and work Pg. #3 Continued:...