Electronic Medical Records Problem in Critical Care Nursing - Essay Example

? Electronic Medical Records Problem in Critical Care Nursing Electronic Medical Records Problem in Critical Care Nursing Introduction The nursing profession, like all others, has undergone and encountered a number of changes and problems. One of these is the phenomena experienced in the provision of critical care. They are brought about by a number of factors that include the present transformation in different fields. As such, they may include the advent of technology, which has forced most individuals and organizations to be conversant with current technology to ensure that they are able to maintain and improve their competitive positions in the various areas. However, the inclusion of technology also requires that those using it possess the knowledge and expertise to prevent inconveniences as well as other errors. Majorly, in the critical care of the nursing profession, it is the involvement of electronic medical problems that poses a big challenge and creates barriers for most nurses (Blair & Smith, 2012). In the provision of health services that include nursing, several records are required for different activities. It is necessary that nursing records are done in a high quality manner. In this sense, therefore, Electronic medical recording has made this process easier by providing easy access and completion of tasks. Nonetheless, it is also confronted by a number of tests that were not present in the previous system. It thus calls for the presence of a number of health care management topics and applications to sort the issue out. Literature Review According to Blair and Smith (2012), some of the problems encountered during nursing documentation include the lack of expression of the critical thinking and rationale applied during clinical decisions and other interventions. These are usually extensively provided when written documentation is done for the patient. In this way, the progress of the patient is usually hard to indicate and follow. They, however, indicate that this problem can be sorted out through the applications that include the use of narrative charting and focus. The issue of problems brought about by the electronic medical recording in critical care nursing is discussed by Baisch (2012) who discuss the lack of ability by many of the electronic health systems in public hospitals to show specificity. As she indicates, most of the time, they are not able to make a distinction between levels of health care that are individual or population based. At times, the limited nature of resources does not allow for the promotion of competent effective levels among the services provided by public health nurses. With this, the broad scope present in everyday practice lacks sufficient evidence. However, the author provides the use of an electronic method as an intervention to capture the ability of public health nurses. In the same sense, Estrada (2012) discusses the use of electronic health recording in the planning of care among registered nurses. A high satisfaction and positivity is shown, in comparison to the previous baseline techniques, hence a better and advantageous tool. It is because it provided nurses with terminology to be used easily in diagnosis and interventions applied in planning care. It thus provided a lot of satisfaction among the nurses who were using it. Nonetheless, some problems such as the lack of agreement on statements of care plans that helped them to determine the status of patients needs in nursing care were recorded. Conrad et al (2012) also point out that there are a number of barriers that are presented by the documentation of nursing standards. This is despite the fact that it utilizes the standard nursing language. However, those presented in the ambulatory nurse practice are identified and perceived. On the other hand, Brooks (2011) shows the benefits of the electronic health recording system by a nurse. She notes that EMR increases safety and the quality of services provided to patients. In addition, the accessibility of information is quick and easy, and medical practitioners are able to reduce errors and make better decisions that are related to healthcare. In this sense, information and knowledge is transferred in a fast and proficient way. The issue of safety created by electronic medical recording is also stressed by Clarke and Donaldson (2008). They emphasize that this step helps nurses to provide high quality patient care in hospitals as well as the patient outcomes. Thus, in relation to nurse staffing and its importance in the provision of critical care electronic medical recording is vital in making the quality of nursing indicators standard. With this, the services that are sensitive to nursing outcomes possess more visible outcomes. Method In order to confirm this, it was necessary to conduct an interview with a professional individual who is experienced in the same field. The individual was able to give insight on how this problem is experienced and tackled in his organization. This will make it easier to collect more information as well as confirm what has already been acquired from the peer reviewed texts. In addition, the healthcare professional was able to share the concerns of this health care problem in depth and the impact that it bears on all those who are related to it. In this relation, I chose to interview the ICU staff nurse at the California Pacific Medical Center, San Francisco since it will give a lot of information that will help me deal with the same problem once I get to that position. Some of the research methods, therefore, used in this interview included a face to face interview, presence of a written questionnaire and the use of a phone interview. Analysis From the interview, I discovered that a lot of professionals in the nursing field still bear the occurrence of several challenges that relate to the use of technology. They mainly comprise the junior members of staff in the organization. However, even most of the experienced professionals usually face some difficulty. The electronic recording system, like other procedures possesses its advantages and disadvantages. Its advantages include easy access of information from different locations, ability to see the doctor’s notes as well as the ability to view patient history in the long term. However, it shows that a number of strategies can be used to minimize some of the challenges that include hacking and access of the patient or other information by the inappropriate people. In addition, software requirements and power failures and shortages that lead to the loss of vital information also present problems. Conclusion It was, however, discovered that, despite the problems encountered during electronic recording, it is still more preferred than the written medical record due to the advantages that are involved. It is because of this that though slowly most of the nurse managers have accepted to change from the paper works used traditionally to electronic medical records. References Baisch, M. J. (2012). “A Systematic Method to Document Population-Level Nursing Interventions in an Electronic Health System”. Public Health Nursing, Vol. 29 Issue 4, p352-360. Blair, W., & Smith, B. (2012). Nursing documentation: Frameworks and barriers. Contemporary Nurse: A Journal for the Australian Nursing Profession, Vol. 41 (2): p160-168. Brooks, R. (2011). Embracing EMR: Nurse Managers can Lead Nursing toward Informatics Competencies. Retrieved 4 Nov. 2013 from http://nursing.advanceweb.com/Columns/Nursing-Informatics/Embracing-EMR.aspx Conrad, D., Hanson, P. A., Hasenau, S. M., & Stocker-Schneider, J. (2012). “Identifying the barriers to use of standardized nursing language in the electronic health record by the ambulatory care nurse practitioner”. Journal of the American Academy of Nurse Practitioners, Vol. 24 Issue 7: p443-451. Clarke, S. P., & Donaldson, N. E. (2008). “Nurse Staffing and Patient Care Quality and Safety”. In Hughes, R. G., (Ed.). Patient Safety and Quality: An Evidence-Based Handbook for Nurses. Rockville, MD: Agency for Healthcare Research and Quality (US). Retrieved 4 Nov. 2013 from: http://www.ncbi.nlm.nih.gov/books/NBK2676/ Estrada, N. A., & Dunn, C. R. (2012). “Standardized Nursing Diagnoses in an Electronic Health Record: Nursing Survey Results”. International Journal of Nursing Knowledge, Vol. 23 Issue 2, p86-95. Read More