Nursing Informatics: Principles and Benefits

Electronic Health Records (EHRs)

• EHRs are digital versions of a patient's medical history, including treatment plans, laboratory results, medication information, allergies, and other relevant health information.
• EHRs include a range of data, such as demographics, medical history, medication and allergies, immunization status, laboratory test results, radiology images, vital signs, personal stats, and billing information.
• One of the key features of an EHR is that health information can be created and managed by authorized providers in a digital format capable of being shared with other providers across more than one healthcare organization.

Importance of Medical Records

• To the patient:
  • Helps document the history of the patient's illness
  • Avoids omission and unnecessary repetition of diagnosis and treatment measures
  • Assists in continuity of care in the event of future illness
  • Serves as evidence to support or refute legal questions
  • Assists in fixing disability entitlements
• To the hospital:
  • Provides statistical information for decision-making and resource allocation
  • Maintains documentary evidence for medical audit and quality evaluation
  • Protects the hospital in case of legal questions
• To the doctors:
  • Assures the quality and adequacy of diagnostic and therapeutic measures
  • Assures continuity of medical care
  • Helps in self-evaluation
  • Protects the doctor in case of legal suits
• To the nurse:
  • Helps collect data about the patient completely
  • Applies possible nurse diagnosis and care plan
  • Assures complete documentation for patient care
  • Helps in research and education
  • Helps in self-evaluation
• To the public health authorities:
  • Provides reliable mortality and morbidity statistics
  • Helps plan preventive and social measures to meet community needs
  • Provides early warning of communicable diseases

Characteristics of Good Health Records

• Complete: sufficient data to identify the patient, justify diagnosis and treatment, and outcome
• Adequate: all necessary forms and all relevant clinical information
• Accurate: capable of quantitative analysis

Advantages of Electronic Health Records

• Have the patient's entire history
• Flag drug reaction problems
• Eliminate redundancy in record keeping
• Eliminate the need for taking repeated histories
• Reduce error
• Improve healthcare productivity
• Eliminate duplicate testing and exams
• Eliminate huge amounts of paper generated in creating and sharing paper documents
• Can be stored in a cloud, providing easier access by those who need them

Disadvantages of Electronic Health Records

• Very expensive to set up
• Require standardized coding systems, which force all users to use entries that the computer can understand

Electronic Health Records Applications

• Administrative Applications
• Computerized Physician Order Entry
• Laboratory Systems
• Radiology Systems
• Clinical Documentation

This quiz covers the fundamentals of nursing informatics, including its framework, the differences between data, information, and knowledge, and the benefits of applying nursing informatics. It is designed for nursing students and professionals.