Electronic Health Records and Patient Confidentiality Technology has become an essential part of our everyday life therefore, it makes sense that doctors and hospitals get rid of the old fashioned paper charting and use technology to access patient records. Electronic health records (EHR) provide quick access to information, as doctors no longer have to wait for other providers to fax previous records to them. The accessibility of Electronic Health Records assist medical providers to make quick medical care decisions, by accessing previous care provided to patients including treatment and diagnosis. Quick access to information through EHR enables health care providers to treat patients faster as there is no need for records to be mailed or
The electronic medical record system (EMR) is an electronic record of health information about an individual created, collected, managed, and negotiated by doctors and authorized staff in a healthcare organization. EMM also has the potential to provide physicians, clinical practice, and healthcare organizations. This system facilitates workflow and improves the quality of patient care and patient safety. EMR is a document that contains information on the treatment of digital versions of patients produced and recorded by medical officers who treat and manage patients. It is generally known that the use of Electronic Medical Records (EMRs) in the hospitals of the Ministry of Health Malaysia has had a positive impact in the patient care process
Health information exchange or HIE allows doctors, nurses, pharmacists, and other health care providers and patients to access vital medical information. It also allows them to share medical information securely and electronically. HIE improves the speed, quality, safety, and the cost of patient care.For many years patient's files were stored using paper methods, transferring them by mail, fax or transferred it by hand to every appointment. Changing to electronic file improves the completeness of patient's medical records. It makes decision making of healthcare providers avoid readmissions, avoid medication errors, improve diagnosis, and decreases the amount of times test are reordered.
Assessing patients under activities of daily living can help nurses picture a patient’s everyday life style and later making them aware of simple but important things such as management of fluids, diet restrictions etc. A nurse using this model ensures that they are not missing out on important aspects of care eg. providing an safe environment by ensuring no obstacles are in the way or lifting the chin of a patient with breathing difficulties ensuring safe
It’s tempting to make an assumption that teaching doctors and nursing students to be decision maker will help improve the quality of judgement and decision making. A recent review on education interventions to improve clinical judgement and decision making in nurses found little evidence that existing strategies might be effective( Thompson ,2011). Out of the twenty four controlled comparisons in the review , only seven showed a positive effect and this effects were variable and very few had a clinical significant. We should not be surprised by; more training does not always cause a better performance and the causal relations that educationalists are trying to tap into are so complex. ( Campbell et al., 2000).
The nurses should be keen in attaining the nonverbal messages which are used by the patients in communicating with them. This entails the use of body movements which is used by most patients in delivering mixed messages. Facial expressions and use of touches can also be used in delivering the nonverbal messages (Tee Brown, 2012). All these theories have been used by the nurses in order to understand the conditions of the woman. Through the effective communication criterion, the nurses will be able to know what to give to the woman depending on her body movements and facial expressions while still in the primary stage of treatment.
The Electronic Health Record (EHR) has been, this nurse believes, the turning point in the delivery of advanced patient care. This technology allows for efficient use in streamlining data, and collaboration of care, and the way we communicate. Personal Data Assistant’s (PDA’s), smartphones, and tablets help to simplify technology, placing the patient data in the hands of the HCP that gives the advantage to see a complete picture. The EHR has impacted the way we deliver care. There is access to the record from anywhere, always.
It provides the basis for selecting and implementing nursing interventions. Accurate nursing diagnoses can improve the quality of nursing interventions and lead to better nursing care being provided to the patient (Kurashima et al, 2008). A thorough analysis of the collected data is required in order to make an appropriate nursing diagnosis. Determining the priority of each nursing diagnosis requires clinical reasoning and applied knowledge. The nurse along with other members of the healthcare team then determines the urgency of the nursing diagnoses identified and prioritises care as appropriate.
It is basically the scientific method of problem solving applied to nursing in order to achieve a maximum level of change towards the expected health outcome. It is grounded in a holistic framework which offers the potentials for advancing nursing practice because it provides a frame of reference, centered around the client and family or community to describe, explain, predict and control the outcomes of clients’ care. It restores nursing to its primary commitment, that is, delivering care to people on a one-to-one basis and thereby eliminating the present tendency to relinquish this overall function to those who are not prepared to fulfill it. Nursing process promotes consumer satisfaction. By making the client the undisputed focus of the endeavor, a nurse brings forth a one-to-one relationship in which the client is an active partner and participant in crucial decision making.
It is this emphasis on patient and their needs that allows for tailored judgment and interventions. Moreover, nurses should respect patients’ responsibility, ability and participation for their own health. Nurses surrender their desire to control, and focus on co-operation and collaboration in making judgment (Gibson, 1991). Patient empowerment urged nurses to think out of a patriarchal framework. Indeed, it is the nurses clinical expertise, collaborative skills and their knowledge of the health care system that serves as a source of power that allow nurses to make their care delivery more patient centered (Ponte et.