Electronic Health Records (EHR) (Nursing)

00:01 Now let's switch gears to look at how we can record.

00:04 There's several different methods and it'll be based on facility.

00:08 So one of those is paper recording.

00:11 So there's a lot of facilities that don't do paper recording anymore, but it is still in existence.

00:17 So we paper record, it is episode oriented, and also just keep in mind with paper recording, continuity of care can kind of be lost from each episode.

00:27 Because when we paper record, there's lots of lots of nursing notes like we looked at earlier, so this can be kind of hard to follow.

00:36 Next, another form of medical documentation is narrative documentation.

00:41 So the problem with this, it's more like a story format and you can imagine if someone's doing something in a story format when they document, probably not very concise.

00:51 It can be very long, repetitious, and it can be really disorganized to be honest.

00:57 Now, let's look at electronic health record.

01:01 Thank goodness for the electronic health record.

01:04 Like we talked about, this EHR helps communicate a lot of information.

01:08 The doctors can be on a totally different floor or even at home, and they can access this and we can communicate together.

01:15 So this is a digital version of the patient's medical record.

01:19 And as a student, this is mostly what you're going to be exposed to.

01:22 And again, like we talked about earlier, it definitely improves continuity of care.

01:28 The next documentation you may be seeing is problem-oriented medical recording.

01:34 And this database is organized by patient's health care problems.

01:39 So now let's focus on electronic health record, or otherwise known as EHR.

01:44 This is the gold standard for documentation because of its versatility, its accessibility, and its ability overall.

01:52 So let's discuss five different points of why EHR is so widely used in documentation.

01:58 So number one, it summarizes the patient care information in one central location.

02:04 I don't know about you, but as a nurse, I don't want to look at five different places or six different places to find documentation.

02:11 I think we have a better use of our time, probably with the patients.

02:15 It also allows for fast and more streamlined communication.

02:20 It also allows for multidisciplinary access.

02:24 So why that's important to us? We can read physical therapy notes, the provider notes, or even look at different data points that are important in patient care.

02:35 The other thing for nursing particularly, there's flagging, trending and screening of patient status.

02:42 So this becomes important for us in regards to fall risk assessment and especially vaccinations.

02:49 Lastly, EHR helps to facilitate direct patient care.

02:53 So for example, the medication administration record and barcode scanning for safety.