Effective Documentation" and Electronic Medical Record - Essay Example

Electronic Medical Records Electronic Medical Records Guido shows several advantages of electronic medical record EMR (Guido, .In chapter nine of the book, two important issues emerge i.e. the advantages and challenges of EMR. Guido asserts that EMR has brought significant changes to the health sector. Most importantly, the documentation of medical data remains facilitated in a way that patient care and delivery of health services has significantly improved. EMR provide accurate and complete information on patient history.

The data is accessible and equally up to date. Quick access to patient records has facilitated coordination during medical service delivery and efficient treatment. EMR has also been essential in reducing medical errors and provision of safer care. However, the same presents with several challenges. Notably, some types of cybercrime such as social engineering are targeting EMR. Stealing of patient records or online transmission of the same to unauthorised persons is rampant. Unknown to me previously, there are federal laws that protect the rights of the patient concerning EMR.

Patient data must be kept safe and secure (Guido, 2013). Every health care facility must have a means of assuring the patients of secure record keeping. Moreover, access to any information from EMR requires the patient’s consent or a court order. From both legal and nurses perspectives, EMR has enhanced documentation in the health care sector. Nurses find it easy to relate previous records with the current medical conditions (Page & Schadler, 2014). Indeed, record keeping remains now narrowed to soft computer files rather than hardcopy files that are difficult to sort out.

The legal system has found means of protecting patient information because interference with patient electronic data remains easy to investigate (Simmons & Goldschmidt, 2014).ReferencesGuido, G. W. (2013). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, N.J.: Prentice HallPage, C. K., & Schadler, A. (2014). A Nursing Focus on EMR Usability Enhancing Documentation of Patient Outcomes. Nursing Clinics Of North America, 49(Nursing-Sensitive Innovations in Patient Care), 81-90. doi:10.1016/j.cnur.2013.11.010Simmons, C.

, & Goldschmidt, K. (2014). A Nursing SWAT Team: Using the EMR to Improve Patient Throughput. Journal Of Pediatric Nursing, (6), 705. doi:10.1016/j.pedn.2014.08.007