Do electronic medical records make you feel more like a secretary than a surgical nurse? You're not alone in your frustration. "We often hear people complain that it's like they're doing more typing than nursing," says Erin Sparnon, engineering manager in the health devices group at ECRI Institute, an independent nonprofit that researches the best approaches to improving patient care. The purpose of EMRs is to enable healthcare workers to provide more effective, efficient, coordinated care, not make them better touch-typists. Here are 5 ways digital record-keeping can help you deliver better patient care.
1. Ready access to the patient's medical record. EMRs can update instantly and are easy to read. "Gone are the days of hunting down the record that could still be in the transferring department or being held awaiting signatures," says Jan Kleinhesselink, RN, BSHM, chief quality officer at Lincoln (Neb.) Surgical Hospital. Instead, by simply logging into the EMR, staff can view real-time and historic data that can result in timely documentation and support of care, she says. Plus, you eliminate legibility mistakes. Relying on reading someone's handwritten notes is asking for trouble, says healthcare attorney Thomas L. O'Carroll of Hinshaw & Culbertson in Chicago. "Increased legibility of physician's orders can lead to more accuracy," he says.
2. Improved patient safety. If you store paper charts off-site, you won't know that a certain patient has a difficult airway history, says anesthesiologist Philip J. Arbit, MD, medical director and chief of anesthesia services at Novi (Mich.) Surgery Center. "EMRs make patient histories and anesthesia records instantly available to you," says Dr. Arbit. EMRs can cut down on preventable adverse events, even death. For example, they can prompt you to order deep-vein thrombosis prevention or to document the reasons why it wasn't ordered.