Until the second part of the last century, all medical records were on paper. This system worked fine in an age of family doctors making house calls and patients never travelling far from their local hospital. Our modern society has changed and our healthcare record management has changed as well. Computerized record management (CRM) and Electronic Medical Records (EMR) are poised to increase the quality of healthcare. According to the US Department of Health and Human Services, there are numerous ways that CRM’s are improving quality of patient care. Their web site lists problems with paper records. These include, illegible handwriting, multiple healthcare providers for one patient not communicating, and increased amounts of medical and new drug information. “Patients with chronic diseases such as diabetes or congestive heart failure often have to monitor their blood glucose level, weight, blood pressure, and medication regimens in their homes” (AHRQ, 2012). CMR will allow health care providers to track any abnormal values recorded from patient’s home, eliminating the need to wait until the next appointment which may be a month away. With CMR, patients will be able to go to different specialists who can all plug in to the same medical record. Also, the medical record will follow the patient if he is travelling and needs to receive care far from his primary care provider. The switch to computer records will eliminate time trying to decipher a physician’s handwriting. EMR’s will also be updated continuously with updated medical and drug information. This resource will allow the healthcare provider to keep up to date on all the latest research which will increase quality of care as well. Another aspect of increased quality of care is the patient id band being linked to the electronic record. “The system of linking hospital ID bracelets to patients' EHRs has curbed medication errors” (iHealthbeat.org, 2012).
Active Nursing Involvement
While developing and implementing a CMR, it is very important to get input and direction from professional nurses. Nurses are a critical element in the management of health care records. They are the ones charting, administering drugs, identifying patients, and writing plans of care. According to the Hospital and Health Networks website, anyone who is building a CRM system, needs “to spend time on the nursing units and see how nurses work” (hhnmag.com, 2012). Nurses are the professionals who care for patients. The input they can offer will be useful since they are the ones using the system. Nurses have firsthand knowledge about what really works on the floor and will simplify their jobs while increasing quality of care for the patient. The first step will be for the nurse to give input into exactly what they would use in an EMR. Then, nurses could guide the developers in the actual flow of their duties and charting. Without involvement of nurses, programmers may include items not used by nurses or put charts out of logical order for the nursing process. Handheld Devices
The current trend in computerized healthcare management is handheld devices or PDAs. “The functionality provided by PDAs has expanded exponentially from simple personal organizer to include healthcare databases and applications that check for drug interactions, aid in IV calculations, analyze lab results, provide charge capture information, scheduling functions, prescription refilling and other practice management tasks” (Online Journal of Nursing Informatics, 2001). Using a handheld device, nurses are able to keep current on research, standards of care, and drugs. The nurse will be able to access patient records from the bedside, drug room, or during change of shift report. A PDA will cut down on the spread of germs since each nurse carries her own device instead of sharing a computer keyboard with the entire hospital staff. The handheld device will be able to offer...