Electronic Medical Records Essay

Submitted By heidehuynh
Words: 1657
Pages: 7

1. Paper medical records still have a place in healthcare, but the complexities of healthcare, its information and the numbers of providers that treat one patient are becoming unmanageable by paper files. Discuss the strengths and weaknesses of paper medical records?
The strengths include;
• A patient file can be more mobile
• Documentation is fast so charting can be completed immediately
• No need to wait for an available computer terminal.
• Electronic systems can be slow. Paper systems don’t require electricity so theys are never “down” and maintenance is never needed.
The weaknesses include;
• Possible incomplete charting.
• Complete charts can be misfiled or lost. Possible damaged or destroyed information without a backup system.
• Illegible handwriting.
• Charts can be incomplete with missing labs, diagnostics, and radiology reports or they can be misfiled in the wrong patient chart.
• Some charting is done at the end of a shift and treatment errors may not be identified until it is too late.
• Various abbreviations can be dangerous when misused or misinterpreted.
• A patient may have several very large files with complex diagnoses and treatments.
• Storage for paper files can take a large amount of space and can be costly.

2. Discuss the strengths and weaknesses of Electronic Medical Records and the ways they could help in the delivery of nursing care.
• Data can be entered immediately, in real-time so patient care can be safer and outcomes can be improved by letting providers and nurses have access to the information when they need it.
• Doctors orders would be clear and legible so mistakes could be avoided.
• The information can be located in one central place avoiding loss of information and easily found in case of an emergency.
• Patient information is easily stored and there is no need to wait for a patient file or chart, current information can be immediately provided.
• Calculations can be done automatically by the computer helping to avoid mathematical errors.

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• Current medications along with dosages are noted and the time the nurse gives them can be documented along with adverse side effects and medication compatibility.
• Patient allergies can be visible and noted in several places to avoid mistakes.
• Electric documentation includes “prompts” to streamline documentation and helps to ensure the nurse does complete charting.
• Weaknesses include the lack of ability for systems to talk with each other so they are unable to share information so nurses need to learn more than one system and have different passwords which takes time away from patient care.
• Not all nurses are technologically competent; training will be needed for them to use the system effectively.
• Abnormal lab, radiology and other diagnostic results would be visibly indicated along with normal values.

3. Name three types of Electronic Medical records and discuss each one.
• EMR, used by most healthcare agencies. The provider or agency that creates them will also own and manages them.
• EHRs, all healthcare records beginning with birth will be entered into an EHR system. It will make it easier for individuals to have access to their records and keep track of childhood immunizations and diseases such as chicken pox, measles, etc. The complete medical information will be available to all providers from one central location and are safer than paper medical recorders from being lost in case of a disaster.
• PHRs, are patient centered, owned by the patient and maintained by the patient. They not only give patients access to their personal health records but can also enter information into their own records. This will give patients the ability to review records for accuracy and to keep them up to date and allows more collaborative care between the healthcare provider and patient. PHRs will allow better a higher quality of healthcare by opening communication between the…