Electronic Health Record
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71 Terms
What is an Electronic Health Record (EHR)?
A digital record that stores a client’s health information.
What are the main reasons EHRs are needed?
For client safety, efficiency, and medical record keeping.
Why do student nurses need to know how to use EHRs?
Student nurses need to know how to use EHRs to safely access, use, and manage client health information.
How does an EHR make health care better?
An EHR makes health care better by organizing client information, providing quick access to records, preventing repeated work, and improving client care.
What does redundancy mean?
Repeated or unnecessary information.
What does promoting interoperability mean?
It means using EHRs to safely share health information between different health care systems.
What does promoting interoperability help improve?
It improves data exchange (information sharing), patient involvement (engagement), care coordination, and safety.
How does certified EHR technology help health care providers?
It allows providers to send e-prescriptions, safely share health information, and give clients access to their health records.
What is electronic prescribing (e-prescribing)?
It means a health care provider sends a client’s prescription electronically through a computer system.
What devices can providers use for e-prescribing?
Laptops, tablets, or desktop computers.
What are the benefits of e-prescriptions?
E-prescriptions make sending prescriptions easier, safer, and less costly for providers, clients, and pharmacies.
What does certified EHR technology guarantee?
It ensures the EHR meets requirements, keeps health information secure, and can safely share information with other systems.
What does “meaningful use” of an EHR mean?
Using an EHR correctly to meet health care standards and improve client care.
What does The Joint Commission (JC) do?
A nonprofit, independent organization that checks the quality and safety of patient care.
What is The Joint Commission known for?
is known as a leader in accrediting health care organizations for quality and safety.
Why does JC focus on medication administration?
Because accurate medication administration helps keep clients safe.
What is medication reconciliation?
A process where the nurse checks and documents all medications a client is currently taking.
Why is medication reconciliation important?
It helps find and fix medication differences or mistakes (discrepancies) to keep the client safe.
When is medication reconciliation done according to this section?
is done when a client is admitted to a health care facility.
What is NPSG 3?
focuses on improving medication safety and preventing medication errors.
When did the 2024 National Patient Safety Goals (NPSGs) go into effect?
June 2024.
How can health care providers improve medication safety at every visit?
They should review the client’s medications at every visit (clinical encounter) to help prevent medication errors.
What should clients bring to each health care visit?
A current list of all medications, including over-the-counter (OTC) medications and supplements.
What medication information should nurses communicate during transitions of care?
Nurses should share the client’s current medications and any medication allergies or sensitivities.
What should nurses do with medication allergies or sensitivities?
Report and record them.
What is an adverse drug event (ADE)?
An injury caused by a medical treatment involving a medication.
What is a medication error?
A preventable mistake involving medication that can cause harm or death to a client.
Are medication errors common in health care?
Yes. They are among the most common medical errors in all health care settings.
What is a core nursing responsibility related to medications?
Safely administering medications to clients.
How do EHRs improve medication safety?
EHRs help prevent and reduce medication errors when used correctly.
What framework should nurses follow when giving medications?
The rights of medication administration.
What are the five phases of the medication administration process?
Prescribing, transcribing, dispensing, administering, and monitoring.
Who is involved in the medication administration process?
Multiple health professionals and health consumers.
During which phases do many harmful medication errors occur?
During the dispensing and administering phases.
Why are nurses important for medication safety?
Nurses prepare and give medications (dispensing and administering), which are times when harmful medication errors can occur.
How does the EHR improve the medication administration process?
It improves clear communication between health care providers and ancillary (support) departments.
Why was barcode medication administration created?
To reduce preventable medication errors and human mistakes, such as the wrong time or wrong dose.
What does a nurse scan first when using barcode medication administration?
The client's identification band.
What does the nurse scan after the client's identification band?
The barcode on the medication being given.
How does barcode technology help nurses follow the rights of medication administration?
It automatically checks the medication rights and alerts the nurse if a medication right is incorrect (violated).
Why must nurses be flexible when using health care technology?
Because health care technology (systems) is frequently updated and changed.
What can happen as nurses become more comfortable and skilled with technology?
Health care can rely more on electronic systems and become paper-free (no paper records).
How much time do U.S. health care workers spend on documentation?
About 25% to 41% of their time.
What are examples of nursing documentation?
Charting vital signs, assessments, medications, treatments, and procedures.
What allows health care workers to quickly create and store large amounts of client information?
Electronic documentation.
Where is electronic documentation commonly used in the U.S.?
In mainstream hospitals and clinics.
What challenge do health care workers have with documentation?
They may have difficulty balancing time spent documenting with time spent providing direct client care (actually spending time with and caring for the client).
How can too much documentation time affect client care?
It can reduce the time health care workers spend directly caring for clients.
What are the three important qualities of good nursing documentation?
Nursing documentation should be complete, accurate, and timely.
Why is accurate nursing documentation important?
It shows the care provided to the client and serves as a professional and legal record (legal necessity).
What can happen if nursing documentation is inaccurate or incomplete?
It can disrupt continuous care (continuity of care) and lower the quality of care the client receives.
Why is it important to improve nursing documentation?
To meet legal requirements, reduce paperwork, and follow professional nursing standards.
Are medication errors still a problem in the U.S.?
Yes. Medication errors continue to be a problem.
What technology helps nurses give medications more safely?
Barcode scanning and immediately saving the information electronically.
How do barcode scanning and immediate electronic documentation improve client care?
They help improve client safety and the quality of health care.
Why have most hospitals adopted electronic documentation systems?
Because they have a positive impact on client safety and quality of care.
What is remote patient monitoring (RPM)?
A form of telehealth that tracks client information and quickly sends it to the health care provider.
What do electronic monitoring devices do?
They collect client data and send it to health care providers.
What technology can be used for remote patient monitoring?
Mobile medical devices, sensors, wireless devices, wearables, implanted monitors, smartphones, and mobile apps.
What health information can RPM devices collect?
Heart rhythm, vital signs, blood oxygen (Oâ‚‚) levels, and blood glucose levels.
What else can monitoring devices detect or send?
They can detect motion or send real-time video.
Where can wearable monitoring sensors be placed?
In clothing, elastic bands, or directly on the client's body.
What can wearable devices monitor in real time?
They can detect falls and monitor gait (walking), activity, and sleep patterns.
What does gait mean?
A person's way of walking.
What can RPM do with client information?
It can send, securely store, and share client information with health care providers.
What happens when RPM detects abnormal or unexpected readings?
It can highlight the abnormal data and alert providers and caregivers.
How can RPM send alerts about unexpected readings?
By text message or email.
What extra features can some RPM devices provide?
Some RPM devices can provide access to health records, educational resources, self-care tools, and health care providers.
What is patient-generated health data (PGHD)?
Health information created, recorded, or collected by the client or caregiver to help maintain health.
What information can PGHD include?
PGHD can include a client’s health history, body measurements, symptoms, and health-related behaviors.
How does RPM help clients take control of their health?
RPM helps clients manage their health and become more involved in their own care.