I need to respond to both of these questions with a total of 2 sources. I have been a nurse for 18 years in the Emergency Department. I am taking classes for my BSN with students who have not yet graduated from nursing school. Just in case that helps in your response.
Explain how informatics can improve interdisciplinary communication and enhance quality.
Informatics can improve interdisciplinary communication by allowing all members of the healthcare team to have easy access to a patients record. This increases efficiency and accuracy of communication amongst the interprofessional team members caring for any particular patient. The patient benefits from healthcare informatics by receiving enhanced quality of care and overall continuity. Not only does informatics improve communication, but it also improves safety by decreasing nursing issues such as medication errors (Lavin et al., 2015). Due to the reasons I mentioned above, Lavin et al. (2015) suggests that nurses improve their expertise and knowledge of informatics and the skills that come along with it. Doing this will increase overall quality of care for patients, safety, communication, as well aid in maintaining standards of practice.
2. Discuss 2 burdens regarding nursing documentation via the electronic health record that you have experienced in clinical practice/rotations. What recommendations would you make to improve them?
I have to start out by saying that I have had very little experience in clinical practice using the electronic health record for documentation. Although my experience is limited, I have run into some issues regarding this topic. As a student nurse still trying to learn the very basics of nursing practice, my ability to remember every piece of my assessment without documenting it in real time is not as precise as some of the more seasoned nurses I have worked with. I try writing everything down as I am doing it, but that adds a tremendous amount of time to an assessment that should be done much more quickly. The facility I have had my clinical rotations at has a few computers on wheels that the nurses use outside of the patient rooms to complete their charting when there is no more space at the standard computers. I am constantly thinking about how helpful it would be to be able to use the computer on wheels in the patient rooms. This would allow not only me, but all of the nurses to complete their documentation in real time at the bedside. I believe that doing this would increase efficiency and accuracy in documenting in patient’s electronic health records. Another issue that adds to the burden of nursing documentation via the EHR in my opinion is the high amount of standardized boxes that must be filled out for each patient. It seems strange to me that charting (at least in the facility I have experience at) is not more unique to the individual patient and their admitting diagnosis. Sutton et al. (2020) states that redundant documentation and regulatory requirements for documentation are burdens to nursing practice and largely contributes to the amount of time (50% of their day) a nurse spends charting rather than caring for their patients at bedside. I think that making charting more individualized to each patient and their condition/presenting problems would help decrease the amount of time a nurse must spend charting. I think this could be possible if documentation in the EHR followed the critical pathway for the clients diagnoses/treatments allowing for any variances from the pathway to be charted.
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