How the EHR Affects Patient Care and Documentation An EHR creates a centralized

How the ehr affects patient care and documentation an

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How the EHR Affects Patient Care and Documentation An EHR creates a centralized location of healthcare information for each individual patient. If a patient has multiple providers requiring different specialists, those providers can see what other doctors have been planning for their patient. Internists can streamline making referrals to specialists, which results in all patient information going to the referred provider. This speeds up beginning specialized treatment of the patient’s illness. RNs rely on the EHR to manage their patients during their shift. The EHR provides all the information needed about their patients, including their medication list and administration times, tasks, and orders. The RNs use this information to carry out the patient’s plan of care. How the EHR Will Affects the Quality and Delivery of Nursing Care and Patient Outcomes An EHR improves the quality of nursing care due to the ease of access of patient information. Nurses have an easily accessible reference to each of their patients’ charts and can quickly find necessary information like allergies, diagnoses, medications, and orders. Many EHRs have built-in safety measures to avoid medical errors, like reminding nurses that an
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ordered medication is contraindicated due to the patient having an allergy to it. EHR systems can warn nursing staff of possible adverse effects relating to a medication or task. For example, many hospitals have adopted using the MEWS (Modified Early Warning System) score to identify if patients are at risk of developing sepsis. This score assigns scores to vital signs, labs, and assessments. The higher the score, the higher risk the patient is for being septic. Providers use this score as a reference to take appropriate action. EHR systems provide this early detection protocol, which would result in improved patient outcomes. Quality Improvement Data Quality improvement has become a huge focus for hospitals, which have led to specialized audit departments who continually review patient information to ensure that ordered interventions were appropriate and that staff are following protocols. Many facilities have an infection control department who follow up on patients who have foley catheters and central lines. This department develops guidelines, based on evidence-based practice, that staff and providers must follow to decrease healthcare-associate infections. For example, they will ask “does this patient really need a foley catheter?” To which they will investigate how necessary the foley is needed, and if there are any alternatives to having one. Data is used for QI to reduce readmission rates. Those who work in QI can review a patient’s EHR to find out if the appropriate treatment was given to the patient during their stay. If a patient returns for the same illness, they can review what was done during their last stay and figure out what could or should have been done to prevent readmission.
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