01.01 Introduction to the Electronic Medical Record (EMR)

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Included In This Lesson

Outline

Overview

  1. What is the EMR?
    1. Documenting in the computer system
    2. CMS “meaningful use”
      1. Improves delivery of healthcare
      2. E prescribing
      3. Report clinical quality
  2. Why is it helpful?
    1. Standardization
      1. Record keeping
      2. Assessment findings
      3. Orders
        1. Accessibility
        2. Reduction of errors
  3. Flags or hard stops
    1. Wrong dose
    2. Allergy
    3. Abnormal test results
  4. Legibility
    1. Improved privacy and security
    2. Improved efficiency
      1. Rapid treatment
      2. Quicker documentation

Nursing Points

General

  1. Important with EHR documentation
    1. Potential legal issues
      1. Log off when not documenting
      2. Do not share your password
      3. Do not enter a patient’s chart without cause
      4. Do not ignore warnings/flags
      5. All documentation is time stamped
        1. Do not pre-chart
        2. Goal to chart in real-time
          1. Nothing is ever deleted

Transcript

Hey guys, today I’m going to give you a little introduction into the electronic medical record, also known as the EMR. I am sure most of you have seen what this is as most hospitals or institutions have already transitioned into this type of charting. So in this lesson, I hope to give you a better idea of why we use it, why it’s useful, and tips that are super important for your protection as a nurse. Okay, so what is the EMR in the most basic of terms, it is what you would have documented on paper, but now you are documenting in the computer system. So there are a variety of systems available that your facility may choose to use. In my career, I’ve used three different systems, all have the same basic goal, but with different looks and details. So you may be asking yourself, why has there been such a big push to change over to electronic medical record or electronic charting? 

Well, the CMS or centers for Medicare and Medicaid services, which guys have a lot to do with reimbursement. They strongly encouraged in quotes, strongly encouraged institutions to convert to EMR systems for meaningful use purposes. Well, what is that? So meaningful use basically means improving the delivery of care for patients through various things like E prescribing communication between healthcare facilities through the computer and being able to report clinical quality all through the use of the EMR. Okay. Let’s look a little bit closer at why EMR is helpful in healthcare. Well, first off it allows for standardization with how things are documented. Assessment findings, orders. It allows for more accessibility because between all of the necessary providers, so you aren’t searching for a paper chart anymore, you can just log on and if used properly, there is ever reduction of errors. For instance, if there is a wrong dose, ordered a medication order that the patient is allergic to or an abnormal or critical test result, the EMR has the ability to show a flag or even create a hard stop in the computer and something that you might not have necessarily thought about. 

If you have never seen her use paper charting, but think about those providers who completely horrible handwriting. There are no issues with that in EMR as far as being able to understand what something says. Also, guys, there is improved privacy and security with the EMR as it tracks who enters that patient’s chart at all times. Finally, there has shown to be improved efficiency with the quicker documentation that can come along with EMR, which can mean that a patient receives a treatment faster. Okay. This is the most important slide of this presentation because these things listed here are critical to protecting you and your license. So first off, guys always, always, always log off when you are not documenting on your computer and absolutely do not ever let anyone document under your name even if it is the best nurse ever. Guys, I actually built the EMR where I work and this was one of the things that I stress to all the nurses and still to this day I see nurses let other nurses document under their name. 

Guys, it is a terrible idea. You have to protect yourself. If that case that you’re working on goes to litigation, can you imagine how you would feel if you knew you were not the one who did the documenting, but you are now the one being questioned in a legal case? So along those same lines, never ever, ever share your password. Always remember in the EMR everything is timestamped and completely retrievable. Although you may delete something, it is never actually gone. Nothing is ever really deleted in the EMR. To add to this, do not preach heart and try your best to document and as a real-time as possible as this is the whole purpose of the EMR. Guys, finally, never ever enter a chart if it is not your patient. In my career, I have known nurses who have been terminated exactly because of this issue. 

Okay, let’s do a quick review. The EMR is documentation electronically on the computer, which is encouraged by CMS for meaningful used to improve the delivery of care to patients. The benefits of the EMR are standardization, accessibility, legibility, reduction of errors, improved privacy and efficiency. Super important for all nurses. Always log off of the computer when you are not documenting. Do not share your password. Remember, nothing is ever deleted. All documentation is timestamped and do not ever, ever enter a patient’s chart if you are not taking care of that patient. A few nursing concepts that we can apply to the EMR is health information technology. As we are utilizing technology to optimize patient safety, be sure we are following the legalities of practice within the computer charting guys. That is it on this lesson, on the introduction to the EMR. We love you guys go out and be your best self today and as always, happy nursing.