Lesson 1, Topic 1
In Progress

Electronic Health Record

May 1, 2021

In many health care settings, the EHR facilitates delivery of patient care and supports the data analysis necessary for coordinating patient care. EHRs contain information that is identical to that found in traditional records but eliminate repetitive entries and allow more freedom of access to the database (Figure 3-1). In general, EHRs increase efficiency, consistency, and accuracy and decrease costs. Legibility is a further benefit of these systems.

The scope of the use of EHR for documentation in health care agencies varies depending on the agency. In addition to documentation of nursing care and interventions, most health care agencies have incorporated information systems for management of admissions, billing, and the communication of orders for diet, pharmacy, and diagnostic tests. Use of these systems allows departments within an institution to interact, and it provides a database for research and quality assurance

FIGURE 3-1 Nurses use computer for documentation.

(Nelson, 2014). In addition, agency-wide computer information systems are more efficient because information entered in the system can be automatically transferred to other areas. In regard to nursing documentation, systems often include options for generating individualized care plans, automated Kardex forms, and acuity levels and medication administration records (MARs). Although the terms EMR and EHR are often used interchangeably, a key difference between the EHR and the EMR is that the EHR has the ability to exchange patient data not only within a facility but from one facility to another. The EMR typically is set up to exchange patient data within a facility (National Alliance for Health Information Technology, 2008).

EHR systems vary in the way they are accessed, depending on the facility. Some systems permit computer input only at the nurses’ station; some facilities have bedside systems, also referred to as point-of-care (POC) systems; and others use handheld systems. Point-of-care systems are sometimes housed on wheeled carts referred to as a computer on wheels, or COWs. Charting at the bedside saves time and allows current information to be immediately available to all who need it. Some systems automatically retrieve and record information from electronic devices (e.g., vital signs) and simultaneously enter the data in all relevant locations in the record, which cuts down on duplication of effort. In addition, some systems prompt for certain data to be entered, which results in more accurate and complete record keeping.

Electronic charting procedures vary by agency. Data are often recorded in flow-sheet format for easy storage and retrieval. Some agencies incorporate the use of free-text narratives in addition to standardized phrases, to allow specific and individualized documentation. The standard phrases indicate information such as nursing diagnoses, interventions, and outcomes classification systems. Assessment data, for instance, are entered by selecting from a list of preformulated choices, which means that the accuracy and pertinence of the data entered depends on the nurse’s familiarity with the language the system uses to name the nursing problems, the lists of data for assessment, and anything else that is entered by picking from a list.

Naming conventions, or nomenclature (a classified system of technical or scientific names and terminology), must be considered when choosing computer-based documentation. The field of medical or nursing informatics (the study of information processing) is constantly evolving, which requires that software programs be updated on a regular basis to stay current with changes in terminology. In addition, considerable time needs to be invested in training personnel, both in charting procedures and the terminology the system uses and in conducting ongoing refresher training. Newly hired personnel need to learn a new system even if they have already had considerable experience in the field.

In addition to the EHR, a newer concept known as the personal health record (PHR) is an extension of the EHR that allows patients to input their own information into an electronic database. Although the PHR allows for a more comprehensive profile of the patient, points of contention for the PHR are how the information is going to be stored, who is going to store the information, and what economic costs are involved (Menon, 2012). The PHR may not only contain information submitted by the patient; some systems may allow input of information from other health care personnel such as pharmacists, laboratories, and the patient’s primary health care provider. PHR applications may be managed by various institutions such as private vendors, hospitals, primary care health care providers, and insurance companies. These vendors may choose whether or not to charge a fee for storage of this information (Nelson, 2014).