Charting in the Era of EMR


I am still of the era of nurses that entered a patients room with my rounds sheet tucked into my uniform pocket.  The secret was to not let the patient see this sheet, and be able to remember their name, main diagnosis, and what you needed to check in them.  You would go through your complete assessment including vital signs, and when you left the room you would pull out your little sheet of paper and write down all of the information you just collected.  This procedure was repeated for all eight of your patients.  When you were done, you then sat at the nurses’ station and pulled the individual charts so you could transfer the information onto the required forms. 

It is not hard to see how the electronic medical record has benefited the role of nursing.  The first improvement is in time management.  You can actually take the information and enter it once.  This is the only time you write the information.  The second advantage is in correct data entry.  You can enter the data as you gather it.  There is less chance of forgetting the information before you write it in the patient record.   The third benefit is in gathering the correct information on each patient.  Electronic medical records prompt you to gather the required information.

I speak purely from a hypothetical standpoint because I personally have not had the chance to utilize an electronic medical records system.  Our hospital is still struggling to come up with the money required to purchase and implement a system.  I can, however, dream about how easy it will make my life once we get one!!!

Online Healthcare Informatics Educational Certificate Program

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