Nursing And The Electronic Health Record

Theposition of the American Nurses Association on electronic health records focuses

on the rights of patients.Patient safety needs to be the key consideration, along with better outcomes of treatment.The ANA also emphasizes that the data on the health record needs to be accurately collected, recorded, analyzed and protected.

The organization also stresses the need for privacy and confidentiality of patient records, especially in a time when medical care is becoming more integrated and patient care is delivered by multiple healthcare providers.The ANA also strongly supports health records that are standards-based.

All of those involved in patient care, including nurses and the patients themselves, should be involved in the development, use and evaluation of the electronic health record.

However, information involving nursing care is not often included in electronically stored records, even though studies have shown that such information improves treatment.If nursing information is not included, it will not be used in healthcare planning for the patient.

So, the focus must be to get nursing care data in an electronic format so that decisions involving healthcare will be able to use the input from the nurse.Ignoring nurse information has been shown to lead to inaccurate reimbursements for care, which means that the payments do not represent the real cost of delivering the nursing care.

If nursing data is going to be included in the electronic patient record, nurses must decide what data they should include on the record and what terminology should be used to record the information so that its meaning is clear and universally applicable and consistent.

Currently nurses now use the Nursing Minimum Data Set, which is the information that needs to be collected for each patient.It has been in use since 1985.It includes such things as nursing problems, interventions, outcomes and intensity.

Standardized nursing terminologies, such as the Omaha System, Clinical Care Classification, Perioperative Nursing Data Set, Nursing Outcomes Classification, International Classification of Nursing Practice, have been developed.These systems allow nurses to collect data in a clear and consistent way.But, so far, few organizations have used these terminologies for electronic nursing documentation.

For this reason, nurses need to be involved in developing these new terminologies for use in the electronic medical records.This information will be used for many different analyses of patient care and healthcare practice.These analyses will in turn affect nursing practice in the future.

by:JeanHenshaw

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