'Wgu Nut1\r'

' substructure to the electronic wellness go steady book of account (EMR) adit to the electronic Medical memorialise (EMR) Gary L Williams Western Goernors University submission to the electronic Medical Record (EMR) The virgin millenary has unveild m any(prenominal) throws in the world as we spang it. Our national cherishion which collectmed to be impermeable has revealed its pic to macrocosm br distributivelyed. Remember September 11, 2001 when the hi-jacking of inventi bingles lead to the expiry of the Twin Towers in New York City, and severe metamorphose the Pentagon in Washington DC.Now our wellnessc atomic frame 18 dust has right away moved into the information highway. How you whitethorn ask, with the knowledgeableness of the EMR. So raise the EMR be safe and underwrite? Let us investigate. So near what is the EMR? in that respect argon many formal definitions but the one and only(a) that stands by and pass on be used straight move out is from the wellness anguish turnment and Man erament Systems Society (HIMSS). It states: The Electronic health Record (EHR) is a longitudinal electronic drop of affected role wellness information graveld by one or more encounters in any sh ar speech setting.Included in this information atomic number 18 affected role of demographics, progress notes, problems, medicaments, brisk signs, former(prenominal) medical exam checkup history, immunizations, science laboratoryoratory selective information and radiology reports. The EHR automates and stream product lines the clinicians work run away. The EHR has the ability to generate a complete repose of a clinical patient encounter †as well as patronageing other cargon-related activities directly or indirectly via interface †including evidence-based decision jut out, feature management, and outcomes reporting. (HIMSS) Within this definition thither is a multitude of arranging components.Think of it deal the eightf d isused display to the Electronic Medical Record (EMR) dividers that were found in the motif medical get down. For object lesson, you may see headers comparable, medication record, revisal penetration, nurse minds, the plan of c atomic number 18, education, radiology, cardiology, etc. Under the medication tab lays the eMAR, medication history, and reconciliation. Each band with the click of the mouse go forth open a new file in spot this record. The jut out is formatted to follow a dodgingatic rate of flow with check boxes, drop down lists, or remedy text space to document the patient findings, activities, and assessments.The EMR pass on form many realizes for the entire healthc atomic number 18 group and the patient. By development and normal with the attentionance of chance upon personnel, the EMR should flow and make certificate easier. By having a standardized flow and options to document the standards of care, documenting should become easier and appropr iate more consis hug drugcy. Take for example a pee description. You may see for color description amber, yellow, red, clear, or tea. Then cloudy, turbid, clots, or mucous followed by malodorous, sweet, or pungent. This allow provide a means of potentiality measurement for Evidence-Based Medicine (EBM).How many patients with UTI receiving Bactrim DS pull in amber mucous pungent urine on a GU social unit? Can you see the pattern? The EMR impart assist in small thinking as well. Your physical assessment for instance may be by body arranging or a complete head to walk assessment. These screens allow assist the sustain in reminders of indispensable documentation. The nurse may receive a line list for a certain procedure or required documentation of a high risk of exposure factor, such as fall precautions, to alert the bed brass nurse or technician that the document is due or kick the bucket(prenominal) due.Introduction to the Electronic Medical Record (EMR) The EMR pull up stakes provide real eon info and reports from various disciplines at bottom the healthcare facility. For instance, a Vancomycin trough was ordered at 0700 and its 0900 and the IV medication is due. By selecting the laboratory tab your result result be there in front of you before the dose is administered. The a the corresponding shtup be expected of radiology imagining results, EKG, sample test reports, a bedside capillary glucose test do by the technician. No more searching by means of multiple computing device systems or piles of lab results to find the info you indigence.The information is there and quickly available. Healthcare providers reach the penmanship of a deranged mad scientist. How often do you beget multiple nurses arduous to determine what Dr. Hyde just wrote? What if you guess damage? Now you place that call to Dr. Hyde for clarification when you stool a multitude of things to be doing. With Computerized Provider allege Entry (CPOE), no longe r leave behind snapshot what was written be an issue. Standard order sets will be available with the opportunity to be distinguish or modified from a pre-determined list of ommon orders for turning admission or for specific disease processes like the Acute Myocardial Infarction. Included may be diet, activity, vital signs, IV fluids, labs, EKG, PCXR, or consults. As moved(p) upon earlier with the urine sample report, there is a myriad of potential info that pot be extrapolated to form reports for research and to assist with the EBM. What is the average number of days for patients on the ventilator for June, 2011? How many patients in the rehabilitation unit have pressure ulcers? perchance a nurse imagines to the unit manager that it seems like a large number of the patients on the unit have C- Difficile?A report target be run to show Introduction to the Electronic Medical Record (EMR) trends of the patients with this condition. Maybe it’s a progress washing issue or cross contamination from multi-use bathroom facilities. There are many opportunities that would at crush have been difficult to track from the old paper medical record. Identity theft is rampant in this world of technology. How will the EMR be secured? How toilette the nurse nettle the EMR? Today theatre data processors are almost essential. The same virus and malware that affect your national computer provoke infect the EMR if certificate is lacking.The Information engineering science group will provide the general certification for the system by continuous upgrades to software program like antivirus and firewall protection. Each police squad member will be issued a unique log-in and parole to access the EMR. This must be kept strictly confidential for the nurse’s protection. This secure log-in is like a finger print of the depute user. When the EMR is accessed, there is a snip stamp of what records were accessed, for what aloofness of time, and by w hom. A secure trail of entry into the EMR can be traced. What is the Personal Health Record (PHR) and how does it differ from the EMR?The PHR is essentially the same document that you would produce in the atomic number 101’s Office. The PHR can be completed online all by means of a Physician’s Office or through an immaterial resource. Things that would be included in the PHR might be your name, address, tele reverberate number, date of birth, and possibly the social security number. This record could also contain your Physicians name and phone number, the list of your real medications and dosages, a list of current and Introduction to the Electronic Medical Record (EMR) past medical conditions, and passed surgical history.This type of a record is usually keep by the patient themselves. The PHR will differ from the Electronic Medical Record in that the Electronic Medical Record is property of the Health bursting charge facility and not the consumer. The ain heal th record becomes more vulnerable to breaches in security since it is principal(prenominal)tained by the consumer. For example, I might support my sign on and password to my family or shoplifter to input data for me. This obviously breaches ones security. This allows access to these individuals to alter ones personal health record at will.The website that maintains the personal health record may not be as secure as that of the Health Care facility. The Electronic Medical record is usually maintained by the healthcare facility, outpatient clinic, or Physician’s Office. These healthcare facilities must maintain high security to protect the information within that medical record. In 1996, Congress passed a law entitled The Health Insurance Portability & Accountability Act (HIPAA). This law was knowing: -To improve portability and continuity of health insurance insurance coverage in the group and individual markets. To combat waste, fraud, and insult in health insuranc e and health care delivery. -To reduce costs and the administrative burdens of health care by improving efficiency and effectiveness of the health care system by standardizing the inter transform of Introduction to the Electronic Medical Record (EMR) electronic data for specified administrative and financial transactions. -To ensure defend the privacy of Americans’ personal health records by defend the security and confidentiality of health care information. (James) The security and confidentiality are paramount. Fines are levied as a result of a breech to the HPPA law.There must be alerts to vulnerabilities, safeguards to help protect the EMR and the Information Technology police squad must be able to come across possible threats. Using an EMR (electronic medical record) has no absolute right and wrongs in either computer equipment or software for HIPAA compliance. Usually there are four demesnes to examine: -Physical earnest †can your computers with patient data be stolen? -User Security †can anybody log on to the patient database? -System Security †what happens on a hard drive crash? -Network Security †can unauthorized persons outside your facility access patient data? Milne, 2006) Security is never easy to maintain; it requires continuous safeguarding. As a team we are all responsible to assist in the security of the EMR. Always log on and off when you are no longer Introduction to the Electronic Medical Record (EMR) using the bedside computer. Always check before charting that it is indeed you that is longed into the system and that only one patient record at a time is open for use. The EMR can be a worth(predicate) tool for Quality Improvement (QI). Through the design phase, a number of measurable data can be built into the EMR for report generation.If the team valued to reckon at the number of times vital signs were not documented as dictated per constitution & Procedure. This data can be built into the system and reports run daily, weekly, or monthly. The same thing can be built to monitor for overdue or omitted medications. This can be further expanded to identify which team member is involved and to check for trends. info may also be still to support EBM. For example, tracking the effectiveness of two different antibiotic drug treatment regimens of a selected disease process may be used to support a change in the disease treatment (e. . antibiotic A showed improvement in five days where as antibiotic B showed improvement in ten days. ) Here again the possibilities seem endless. Think of the time savings for all the key people that would be required to look through endless paper medical records for this type of data collection in the paper medical record. So how does the EMR come to recognition? It takes a large team of various specialties and specialists to develop the EMR. It starts with the Healthcare system researching and therefore purchasing the scoop up system to fit the co mpany’s ineluctably and requirements.Once purchased, the owner of the software will deploy a team of specialists that will assist the Healthcare systems team to design and develop the contents and flow of the EMR. The team includes senior management which will assist in the purchase and be the governing authority of the proposed Introduction to the Electronic Medical Record (EMR) work flow before implementation. There are many subdivided teams. treat will have Subject Material Experts (SME) that will be the vowel system to assist in the flow, wordage, and design of the nursing components of the EMR. The SME’s will be from every department of nursing.From this group will be the tops(predicate) User. The Super User will act as the cheerleader for the project development and will be the main source for assisting with the Go Live of the EMR. The Information Technology (IT) will be a multi-tiered group ranging from System Support Analyst or the front line of communicati on, the Computer Programmers and System Analyst or the builders and troubleshooters, to the labor Managers or the supervisors of the IT team. Nursing will also have the Clinical Informatics Application Analyst who will be the voice between nursing and the practiced side of issues, concerns, and development.The End User which is the front lines of nursing and everyone that will be using the system for documentation. And last but not least will be the Educators that will teach the system to the entire team. This is a rather large of individuals working as the voice of the EMR development and implementation. In conclusion, change will be rough at times but change is necessary for progression. Be positive and listen to the teams and the tips that are offered. Assist each other as support with the continued goldbricking and development of the EMR. The Technology age is here and we should all reap the benefits of this endeavor.Remember how Florence Nightingale was the enclosure to nur sing as we know it. Well each of you deserves a pat on the lynchpin as you are the pioneers that have lead nursing into the technology phase of the Electronic Medical Record. You too are a part of nursing history. References HIMSS. (n. d. ) EHR Electronic Health Record. Retrieved from http://www. himss. org/asp/topics_ehr. asp James, R. (n. d. ) What is HIPPA? Retrieved from http://www. dhmh. state. md. us/hipaa/whatishipaa. html Milne, M. (2006, show 6). HIPAA in a â€Å"Nutshell” †Guidelines for EMR and Paper Medical Records Compliance.Retrieved from http://ezinearticles. com/? HIPAA-in-a-Nutshell—Guidelines-for-EMR-and-Paper- Medical-Records-Compliance&id=156737 ten open ended questions. 1. When the EMR is first implemented on your unit, how can you assure the patient that you are capable in your profession? You will explain that you are a seasoned nurse and an expert in the nursing field. Today our facility is introducing the new EMR which will benefit you in the coming(prenominal). This will take a little more time for me to learn and I do not want you to feel like you are being ignored. I may have to ask you a lot of questions as I go through each section.Please feel assuage to ask me any questions or concerns that you may have. Our object is your comfort and safety though the high quality of care. 2. On the day of Go-Live, how can your unit best assist you in providing support as you learn this new technology? My unit manager should over staff initially as we learn the new system. I can foresee the nurse being so buried in the computer that the delivery of care might be too behind break initially. Having the extra staff will decrease the patient load and allow extra hands to assist with the delivery of care. 3. As you learn the new system there will be close to evaluate frustration.How can you divert this frustration so that your patient doesn’t sense that well-nighthing is wrong? We will need to have the Super-U ser and Analyst available to assist us as problems or concerns occur. It is imperative that the bed side nurse remain positive an up commence as we learn. I suggest maybe huddles through out the day away from the bed side to discuss our concerns. We don’t want the patient to feel uncomfortable. 4. Your patient asks you why it is important to have the computer charting. Briefly tell me what you might assert and why? The EMR is being implemented throughout the area as well as world encompassing.As you record develops, we will only need to verify some of your past medical history, allergies, medications, etc. These types of data will flow from one blab to another qualification you care easier as the data is readily available. No more waiting for old charts to arrive and thumbing through page after(prenominal) page of data to look for pertinent information. 5. How do you perceive future benefits of an practical EMR? It will be possible in the future as the EMR progresses, that your hospital record, medico office record, out patient records, and chemists shop to communicate with each other.By doing so, some potential errors may be thwarted. For instance, maybe you are not able to recall all of your home medications and your consulting physician make ups you need a new agate line pressure medication. If the records could speak to each other then this physician would be able to see that you were already prescribed an antihypertensive medication or the pharmacy might catch the possible error. 6. Futuristically, let’s say you take a dream pass to a foreign country. While on your visit you become ill and collapse unconsciously.How can the interoperable EMR potentially be a benefit in this case? If the system develops into a world wide communication link, then with limited data peradventure the hospital in the foreign country would be able to access and utilize my EMR to provide answers in how to deliver the best possible care for me. So if I w ent in with a suspected ruptured appendix, by accessing my EMR surgical history it would be noted that I have had an appendectomy ten years introductory so the focus could be directed at another possible cause. 7.Your patient states to you that she hates the computer and that it is the devils advocate. She is teary and appears anxious. How might you handle this as you are in the middle of documenting in the EMR? You should stop what you are doing and maybe sit beside the patient and gently hold her hand and ask what seems to be troubling her? She might say she feels the nurses spend more time touching the computer and no time touching her, as you just did, and that we come across as cold and not caring. We need to realize that patient action is take over paramount to the overall delivery of care.Take time to interact with the patient. Then step back and document; perchance explaining what you are documenting and why it is important to her care. 8. What do you cry will be your plan of action when the computer system is down? What will be your back up plan? If the computer is down for a set amount of time, as determined by the hospitals administration, then the paper chart will be utilized. If the downtime is for an extended period of time, then this data would be scanned into the EMR as soon as possible after the computer system is back on line.If the eon was short, say an hour or so, then this data should be manually documented back into the EMR with the assessment time documented. 9. How do you anticipate computer physician order entry being a benefit? For one legibility! No more trying to decode what you think may have been written. It will be clear and telegraphic. Also the physician may be able to look at documentation form somewhere other than the patients unit and decide orders need to be given. He can only do computer order entry and a task will appear for new orders.If the order is anything other than routine, a call should be set to alert th e nurse of the priority. 10. What do see as a benefit to Quality Improvement by the institution of the EMR on a unit rear end? We will be able to track data at a faster and higher the true a opposed to thumbing through paper record after record searching for data collection. The data collected can be as concise as to a particular nurse or a specific health issue. The data collected helps to support EBM change.\r\n'