I have been using Electronic Medical Records (EMR’s) since 2004, yet I am just now learning about the science behind the systems in this Nursing Informatics class. I feel like I am learning a new language due to the number of new terms I have encountered in my reading assignments. This is knowledge that I can use in my profession but would not have pursued if not for this class.
While practicing nursing I regularly use four of my five senses. For example, I use my vision to look at my patient and at monitors. I use my sense of smell to determine if a wound infection is present. I use my hearing while communicating with the patient or listening to their lungs. I use touch to communicate reassurance to my patient and their family and also for palpation. McGonicle and Mastrian (2009, p. 18) taught me that the information I gather through my senses and input into the patient’s EMR is an information system. The information I gather and input into the patient’s record is relevant to the patient’s care and the health care system has software in place to ensure the integrity of the data. I have learned that my interaction with a patient’s record is an information system.
A patient has the right to access their EMR and the right to a copy of their health record. Different facilities have policies in place that a staff member must follow for release of the record to the patient. I find the contact in the facility that has working knowledge of the information release process and work with them in obtaining chart contents for a patient. An electronic copy of the chart will remain with the originating facility. The patient owns the information contained in their health record, but do not have sole rights to the contents of their chart. Anyone accessing the medical record is electronically recorded.
I have worked with Meditech at two facilities and Epic at one facility. I like the ability to access a patient’s history from the electronic record. I can look for lab trends. I am able to easily obtain radiology results for a doctor. Whatever I access in the record is (for the most part) legible. I no longer have to call a doctor asking them to translate their written orders. I do not miss carrying around a paper chart (or multiple charts for a chronically ill patient) when transferring a patient from one department to another. I prefer the Meditech systems I have worked with over the Epic system. I find the Meditech system easier to navigate. I find the Epic system requires multiple steps to input data. I can count nine steps that are required to enter an order for a specimen that is on its way to pathology. Ordering a lab has even more steps. This is time spent with at a computer rather than with a patient.
The negative of using an EMR is that only the authorized users in that particular health system have access to a patient’s record. Computer systems between health systems do not talk to each other. President Obama has set a goal for the military and the V.A. to implement a system where a soldier’s EMR can follow them from active duty care to V.A. care. This will help with a patient’s continuity of care.
Tags: Electronic Medical Record (EMR); Nursing Informatics; information system
March 12, 2010 at 3:18 pm |
GREAT job! Well done! We do so much gathering information that we don’t give ourself enough credit for what we do!