Incorporating Standardized Nursing Language in the Electronic Medical Records

Transitioning from the conventional paper-based systems to the Electronic Medical Records

(EMR) software offers a much improved approach in the documentation of medical records.  One feature that Electronic Medical Records offer is the incorporation of standardized nursing language which will make the nurses in the healthcare team work more efficiently in a well-coordinated manner and at the same time limit the likelihood of lawsuits secondary to clinical errors. Compared to the paper-based medical records, the EMR does not allow problems that are inherent to the paper-based medical records that can jeopardize both medical and nursing practice.

Electronic medical records allow coordination among the members of the healthcare team, which means that all those who are directly involved in the care of the patient are able to access the patient’s medical files whichever department they maybe at the moment; whereas with the traditional paper-based medical records, only one person is allowed to handle and access the patient’s file at a time.  There is also a greater chance of accidental misplacement and/or loss of some of the files in the patient’s chart with frequent flipping through thick pages and/or handling to find pertinent information leading to redundant requests of laboratories, x-rays and prescription of medications.

It’s not only the nurses in the wards who will benefit from electronic medical records but also the nurses in the Operating Room Complex.  The electronic medical records are also customized to meet the requirements of all those involved in the medical and surgical setting. Nurses who are assigned in the perioperative care of the patients have different tasks and language documentation that are inherent only to perioperative nursing practice.  With the incorporation of standardized medical perioperative nursing language in the EMR, perioperative nursing documentation can be performed in a consistent and uniform manner.

Nowadays, despite the high costs of some of the EMRs in the market, more and more hospitals in the U.S and in some parts of the globe are gradually transitioning to electronic medical records.  One main reason for this is that the EMR  system interconnects all departments – pharmacy, ancillary, laboratory, care management, administrative, and billing sections.  With these departments merged, smooth workflow of the entire healthcare organization is warranted because of improved communication among healthcare providers and efficacy in work.

Electronic medical records software also safeguards the nurses who are the primary contacts of the patients from medication errors.  Most often, nurses are having trouble deciphering some physicians’ handwritings.  This sometimes leads to misinterpretation of drug names and medication errors.  With the EMR incorporated in the care delivery system, nurses are able to comprehensively monitor on the computer all pertinent information regarding medication prescriptions and drug administrations.  The EMR software also comes with alerts and alarm signals that prompts the physician for any miscalculations of drug dosages and  drug interactions based on the patient’s present and past medical history that are keyed-in in the during history taking. Preoperatively, nurses in the recovery unit can also access the patient’s therapeutic records and be able to correlate medications that are given preoperatively like prophylaxis antibiotics, intraoperatively like the type of anesthesia given and the medications that are about to be given postoperatively.  With the nursing language being standardized nurses are able to document all of the nursing care and interventions rendered to the patient accurately.

The benefits offered by the electronic medical records results in direct amendment in the standard of care being offered by the healthcare organization or facility.  Comprehensive and immediate access to the patient’s medical records via the EMR, physicians, nurses, and other members of the healthcare team are able to provide better, specific, manageable, attainable and realistic management in a timely manner.