The Electronic Health Records Documentation (EHR) or Electronic Health Data Recorder is a program in health information technology created in order to facilitate and speed up health documentation including nursing care.
This system allows nurses to save more time and nurses will be at the patient's side more often to provide care. However, some people consider the change to paperless documentation in health services to be expensive, so not everyone is enthusiastic about the EHR program
It requires good preparation and planning as well as program testing on hospital staff and health service users before implementing EHR to anticipate problems before they occur. The implementation of EHR is a demand and need for every health service facility because it is expected to trigger an increase in the quality of health services.
In order to improve the quality of nursing care services, nurses must be able to provide nursing care with a nursing process approach including assessment, planning, implementation of plans and able to carry out evaluations and follow-up plans to patients who are their responsibility. All these processes must be properly documented by nurses through the nursing documentation process.
The low Quality of Written Nursing Documentation
Documentation is a record that contains all the information needed to determine nursing diagnoses, formulate nursing plans, implement, evaluate actions that are arranged in a systematic, valid and morally and legally accountable manner. Currently, it is reported that the quality of written nursing documentation (paper-based documentation) is still low. Some nurses feel burdened by the time spent in the documentation process.
Thinking about computerized nursing documentation is an alternative solution to save time in health services (Macdonald, 2008). The Electronic Health Records Documentation or Electronic Health Data Recorder has grown rapidly overseas. The program was created in order to facilitate and speed up the documentation of nursing care made.
The Electronic Health Records (EHR) is expected to be used in all health facilities/agencies in the United States in 2014 (Smith, et al, 2010). All health agencies are predicted to have EHR in the future to ensure safety and better documentation in health.
A study on Electronic Health Records Documentation in Nursing at Magnet Hospital in Southwest Florida that examined nurses' needs, preferences and perceptions regarding the EHR documentation method showed that more than a third of nurses (36%) felt EHR reduced workload. Furthermore, 75% of nurses think EHR improves documentation quality and 76% believe EHR improves patient safety and care.
The Program is Made to Make it Easier and Faster
The EHR program was created in order to facilitate and speed up the documentation of nursing care made. With this system nurses can save more time and nurses will be next to patients more often (Moody, et al, 2004).
On the other hand, for some reasons, the shift towards paperless documentation in health care is considered expensive by some, so not everyone is enthusiastic about the EHR program. Some nurses accept it well but there are still nurses who object to the implementation of EHR (Sassen, 2009).
Conventional paper medical records are considered inappropriate for use in the 21st century, which uses information intensively and an environment that is oriented towards the automation of health services and is not centered on a single work unit. Especially for a country with a dense population.
What is the description of the implementation of Electronic Health Records (EHR) in the field of nursing in your country? What are the advantages and challenges of implementing EHR in health care facilities that you feel? Please provide your feedback in the comment box below.
On the next occasion I will discuss the Concept of Electronic Health Data Recorder. So, please continue to monitor this dutyfile blog, okay?
Check the Notify me box to get notified via email when someone replies to a comment.
URGENT...! Make sure your comments are in the form of questions, corrections, or other similar things that are USEFUL (for you or maybe for other users in the future). Comments that are trite (such as thanks, hopefully useful or something similar) will be deleted