EHR essay assignment

Editorial Team / Admin · Dec 18, 2014

If you're in a nursing class, have you had any clinicals yet where you've had the opportunity to care for patients? Start with what the basics of an electronic health record are: an electronic version of what would be in a patient chart. What types of information would you expect to find in a patient chart and how do nurses use this information?

KelRN215, BSN, RN · Dec 19, 2014

I imagine you haven't done clinicals yet because, if you had, you would have seen EHRs in use.

Have you been to the doctor lately? Have you noticed how EVERYTHING they do is on the computer?

nurseprnRN, BSN, RN · Dec 20, 2014

I am going to break my rule on giving too many answers because I see all the time how people totally lack understanding of the many critical ways medical/health records are used because of lack of wider perspective.

Although I can understand that how you stand depends on where you sit, there are far more points to be appreciated and considered for any system of medical records.

If you sit in a hospital patient care unit, it might be all about "faster and more effective quality patient care" (memo: everything has quality-- the word does NOT always mean "good quality" :) ). But that is a very limited view of the world.

If you are in the billing department, it means a way to recover the costs for your institution, without which there will not be as much money to pay for staff and facilities.

If you are in the risk management department, it's a way to follow trends and identify problems and how the solutions are working.

If you're in the supply chain, it's a way to discover what supplies or gadgetry is used, how often, and where.

If you're in the legal department, it's a way to demonstrate compliance with standard of care in the event of a lawsuit that calls it into question.

If you're from the associated educational institution or an internal audit or research team (like infection control), it's a source of data for research and an irreplaceable teaching tool.

If you're a clinician, it's a communication device between team members and post-discharge caregivers.

If you're administration, it's a source of data to allow you to recertify as a provider or keep your facility license.

I hope this gives everybody a fuller appreciation for why charting in whatever form is so important. There are so many uses for medical records, and you should keep them all in mind when you chart. Really.