Introduction to Electronic Health Records

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Presentation transcript:

Introduction to Electronic Health Records Ann E Bancroft, BSN RN Introduction to Electronic Health Records

Objectives Identify the legal beginnings of EHR Identify the impacts of the EHR upon nursing Recognize the EHR as an inter-professional communication tool Recognize electronic charting as an evolving, ever-changing medium requiring continuous adaptation

A Little History Affordable Care Act: “implement activities to improve patient safety and reduce medical errors through the appropriate use of best clinical practices, evidence based medicine, and health information technology” (ACA, 2009. p. 31).

A Little More History… American Recovery and Reinvestment Act of 2009 Improve quality, safety, and efficiency of patient care Engage patients and families Improve coordination of care Ensure privacy and security of personal health information Improve population and public health (Wilson and Newhouse, 2012. p. 396)

Impact on Nursing Documentation of patient outcomes Improving nursing work flow Evidence-based practice Support nursing assessments and interventions Improved inter-professional communication

Benefits of EHRs Immediate access to health care records Improved interdisciplinary communication Improved efficiency Improved quality of care

A Quick Glance

Nursing Assessment

Diagnostic Results

History and Physical

Patient Education

Medication Administration Record

Into the new world…

References Baille, L., Chadwick, S., Mann, R., & Brooke-Read, M. (2012). A survey of student nurses’ and midwives’ experiences of learning to use electronic health record systems in practice. Nurse Education in Practice. 13, 5. 437-441. Retrieved from http://dx.doi.org/10.1016/j.nepr.2012.10.003 Bolla, Y. (2011). Meaningful Use 101. Nursing Management. 42, (2). 18-22. doi: 10.1097/01.NUMA.0000399803.14328.72 Dimick, C. (2009). Defining "Meaningful Use" in ARRA. Journal of AHIMA. Retrieved from http://journal.ahima.org/2009/04/29/defining-meaningful-use-in-arra/ H.R. 3590--111th Congress: Patient Protection and Affordable Care Act. (2009). Retrieved February 6, 2013, from http://www.govtrack.us/congress/bills/111/hr3590. Wilson, M. L. & Newhouse, R. P. (2012). Meaningful use: Intersections with evidence-based practice and outcomes. Journal of Nursing Administration. 42, (9). 395-398. doi: 10.1097/NNA.0b013e3182668162