Information Technology:Benefits to Nursing and Patient Care
by Penny Clowe, Graduate student, University of Houston–Downtown
Nurses seek to reduce medication errors and increase patient safety. The Electronic Medical Records system (EMR) helps by serving as a foundation for a patient-focused information system. Nurses are required by their state practice act to follow “general” standards of documentation to ensure patient safety. Using EMR documentation software, nurses institute a plan of care and establish patient information management. The medical records hold all patient information regarding status, care, medication, procedures, test results, and doctor's orders that encompass the patient's hospitalization period. EMR software stores and manages this information through patient data pathways (location specific links).
Health information, because of its importance to all caregivers and health information managers (HIM), must be viewed as a universal document. Through EMR, this information becomes important for case management, as well as case reviews. EMR software tracks patient variances and provides patient care summaries specific to each provider (nurse, physician, x-ray technician, and others).
Complete information is vital to patient safety because it must be accessed for patient care decisions. The transition from handwritten documentation to EMR also improves safety and reliability of document interpretation. EMR allows instant retrieval of data for cross-tracking patient information and compiling patient summaries. For instance, EMR records and stores patient care errors, and hospitals use this data to improve error prevention strategies. EMR's data, if recorded and stored in a consistent manner, enhances interpretation and makes insurance coding easier.
The exchange of patient records between hospital departments necessitates universal care vocabularies. EMR provides that opportunity. The International Council of Nurses (ICN) promotes the use of these vocabularies and classifications. For instance, an order received for a medication could read “x2d,” which could be interpreted as “x two days” or “x two doses.” EMR software terminology would not accept this coding, and the software program would enforce user conformity by requiring complete, approved data information. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO), together with nurses, physicians and other integral providers of care, will define the use of abbreviations and the need for a universal style.
Nurses benefit from EMR facilitation of patient data. From this EMR data, nurses obtain rapid overall pictures of patient status. Today, the computer records patient data during emergency situations through wireless monitoring. In the past, nurses hand-documented information while simultaneously attending to the emergency. The EMR advantage to patient data access improves decision-making such as detecting patterns and changes in patient status. Pop-up warnings alert nursing staff to abnormalities. Doctors, as well, manage patient care off site through the Web by observing the patient status information.
Most of the new technology increases patient safety and simplifies the care routine, but some technology can create extra steps for the nursing staff. One example is a new bar-code system for administering medication. The nurse scans a bracelet worn by the patient and scans the medication to verify the match. The extra steps of scanning bar codes and carrying the bar-code reader are minor inconveniences compared to the safety benefits.
Regardless of computer efficiency, standardized nursing documentation must allow for nursing clinical judgments. The nursing process implies that nurses administer care and manage the information regarding that care. Current electronic trends indicate that a computer will suggest nursing diagnosis and care plan implementations. The EMR benefit as a means to record and store information and organize data is undeniable; however, the nurse's observations and intuitive understanding of the patient should not be compromised by computer-generated patient care. While Electronic Medical Records manage patient information, the nurse interprets patient information to provide safe and compassionate patient care.
Van de Castle, Barbara, Jeongeun, Kim, Mavilde L.G. Pedreira, Pava, Abel, Goossen, William, Bates, David W. 2004. Information technology and patient safety in nursing practice. International Journal of Medical Informatics. Vol. 73. 543-546.
World, Heather. 2004. Off the charts. Nurseweek. September 20, 2004 .
Penny Clowe graduated from Washburn University in 1979, obtaining a bachelor of science in nursing. She has worked predominantly in the cardiovascular field of nursing. Currently, she attends graduate school full-time at UHD and is majoring in Professional Writing and Technical Communications.