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Computerized Medical Records and Their Quality Advantage

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Computerized Medical Records and Their Quality Advantage

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    There is a strong trend towards computerized medical records. This method of recording information about a patient offers many advantages. One of these is quality.
  • Computerized medical records manipulate and display information in a way that no paper and pen system could duplicate. All notes related to a specific aspect of care can be collated and printed out. The paper chart cannot be reorganized in this manner, nor can it be merged with records from another facility or healthcare provider.
  • Medical records can be used to more effectively track outcomes of care. Instead of using ineffective methods of treating medical problems, data collected about outcomes can be used to define the most appropriate approaches to care. This would facilitate clinical research and outcomes analysis.
  • Electronic charts standardize terminology to conform documentation to common terms and permit aggregation of data. For example, one handheld PC program designed to document risk assessment and pressure ulcer documentation resulted in all wounds being documented in an identical manner with very little room for misinterpretation. An aggregate of all wound data allowed for real-time review by clinical managers and administrators. [36]
  • Electronic medical records (EMR) promote standardized documentation, providing consistent information about patients.
  • EMRs help support evidence-based criteria. Standards of care are supported when the system prompts the nurse to enter information that conforms to appropriate protocols.
  • Continuity of care (CCR) records would permit ready access to an individual’s healthcare information. For example, a CCR system would permit the emergency department staff to determine the medical history of an unconscious patient brought into the emergency department of a hospital.
  • Electronic medical records may improve a facility’s ability to recruit and retain healthcare providers. Anecdotal information has shown that computers tend to increase job satisfaction and morale. This is a significant advantage, given the high economic cost of turnover.
  • In some systems, the patient can access parts of their medical record over the internet. Links to sites that provide information about medical conditions could be made available.

There is one important warning. Inaccurate information can find its way into the computerized medical record, just like a paper chart.

From Nursing Documentation, in  Nursing Malpractice, Fourth Edition

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