Nut Task 2

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Nursing Informatics Task Two: Implementation of an EMR
Jessica Johnson, RN

Thursday, July 26, 2012

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Implementation of the Electronic Medical Record (EMR)

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How the EMR System Benefits Nurses



Patientʼs entire record, potentially from birth, at your fingertips

" Nurses will no longer need to track down paper charting, allowing them to spend more time with the patient. A complete and accurate health history allows nurses to provide safer, more effective care.



Reduces the risk of medication errors

" Chances of giving a patient the wrong drug or dosage due to illegible handwriting are decreased. Barcoded medications and patient armbands also decrease the risk of administering at the wrong time or to the wrong patient.



Simplifies access to documentation during emergencies

" Complete documentation from all care providers can be quickly and easily accessed at the bedside during an emergency. Records can be searched and sorted with a single click instead of spending time searching the unit for a lost paper chart.

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Provides aggregated data for analysis and monitoring of trends

" High infection rates can be scrutinized for a common link, or increases in adverse events can be analyzed to improve patient safety and provide better care. Information is easily sorted and compiled to provide various reports that are user-specific.



Safe and secure

" Threat of loss or damage to an EMR is minimized due to secure storage and backup at an offsite location. Access to the EMR requires an approved user to submit their user name and password. It also tracks all the information accessed by that user. This ensures information is accessed on a need-to-know basis only and patient confidentiality is maintained.

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Better communication between specialties and facilities

" EMRs are easier and faster to review than paper-records, making them more cost-effective. Care providers can simply log into the secure server to view the patientʼs history instead of waiting for the inter-office manila folder to be assimilated, delivered, and reviewed. An EMR can be sent via a secure channel to a physician in a separate facility for consultation in seconds.



Provides nursing data

" EMRs help to provide evidence-based practice for nurses. Retrieving information from paper records, which is where most nursing documentation is stored, is a labor-intensive, hence expensive, task (Thede & Sewell, p. 288). In the absence of nursing data, too often nursing is measured by negative qualities, such as adverse events (Ozbolt, 2000).

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PHI is Vulnerable
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One computer stores virtually unlimited health records. Access by an unauthorized user would breach confidentiality for countless patients. Records can be accidentally sent to unintended recipients Patients can access their own records from computers that havenʼt been logged off Computer screens can be easily seen by people standing behind the user Hackers could infiltrate firewalls to gain access to EMRs User names and passwords that are written down can then found by someone seeking access to EMRs illegally.

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Security Measures to Ensure that HIPAA Regulations are Met
Access Control - Only authorized persons are allowed to access protected health information (PHI). Audit Controls - Hardware, software, and/or procedural mechanisms to record and examine access and other activity in information systems that contain or use PHI (US Department of Health and Human Services, 2012). Integrity Controls - Electronic measures must be put in place to confirm that PHI has not been improperly altered or destroyed (US Department of Health and Human Services, 2012). Authentication - a login process that authenticates that the person using the system is permitted access. Case-sensitive,...
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