Nut Task 1/Electronic Medical Record

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Electronic Medical Records

Progress into the future Melissa D Pipes, RN

Benefits to Nursing Staff


Easier charting, more detailed choices resulting in more in depth physical assessment documentation. Immediate tallying of intake and output ratios, potentially averting a negative patient outcome.



Benefits continued...
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Timely charting resulting in less overtime. The ability to chart at bedside, allowing more contact with the patient. Test results readily available from past to present visits for trending positive outcomes.



EMR; Medications


Allows the nurse the ability to scan medications and patients identification bands resulting in less med errors. Give the staff the ability to print drug information and monitor potential adverse reactions between medications. Allows pharmacy to monitor administration times and set protocols leading to improved patient response and shorter stays.





Impact on Patient care


The addition of technology to the medical profession will only improve the method of healthcare delivery for patients and staff. Paper records will become obsolete and delays will no longer be an issue when visiting physicians in the office. Getting the important results to patients quickly will result in faster treatment and save lives.





Further impact on care


The ability to chart assessments and data in “real time” or access test results while rounding with physicians will improve the quality of care provided by allowing immediate access.

Protection of patient information


Health information made available on any computer is at risk for breach of confidentiality. Hackers are much more savvy and can potentially access results to any patient file. Specific measures that should be in place are password protection for staff only with mandatory password changes every six months.





Safety measures


Staff members who use the facility services shall have their files marked sensitive and tracking measures will be in place to monitor any unwarranted access. No outside access to patients files will be granted from outside the network or facility. Any transference of medical information should involve the interdisciplinary team.





Further safety measures


Password protected accounts with limited access dependent upon credentials. Monitoring system in place to report HIPPA violations and disciplinary protocols in place. Test results and records only discussed with family members or POA's as delegated by the patient.





Medication carts/MAK carts


Nursing staff should be educated regarding the importance of leaving no document open on the desktop while the cart is unattended. Privacy buttons or minimizing screens will be required and enforced to protect patient privacy.



Quality Improvement Measures


Ability to monitor flow of information if multisystems are in use. Monitor and police systems for illegal activity. Identify potential threats for violations. System upgrades and maintenance. Identify adverse effects and monitor trends in timely documentation.



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QI Measures


Criteria set forth for triggering sepsis, VTE risk and communicable disease reporting. Prepare reports for quality assurance . Input of data for lab, radiology and transcription and patient demographics. Evaluate quality measures and trends as mandated by the federal government for reimbursement.

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Team Roles/Superuser
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Staff training both initially and annually. Monitor and reports system problems and issues with function. Assure patient confidentiality is held to the utmost standard.



Team Role/Nursing Care Manager


Monitor timely charting and documentation for nursing staff, monitor trends and identify problems. Educate staff as needed. Maintain patient confidentiality. Discipline as necessary for violations.

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Team Role/ Staff Nurses


Become...
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