Electronic health records and information technology

INTRODUCTION
Computers have become a part of everyday life for many people,
including nurses. Computers are used for educating nursing students
and clients assessing, documenting, and testing client’s health
conditions managing medical records communicating among health
care providers and with clients, and conducting nursing research. All
nurses must have a basic level of “computer literacy” (the knowledge
and ability to use computers or technology) in order to perform their
jobs

Technology in nursing practice

Many activities of the registered nurse involve collecting, recording and
using data. Computers are well suited to assist the nurse in these
functions. Specifically, the nurse records client information in computer
records, accesses other departments information on the client from
centralized computers, uses computers to manage client scheduling,
and uses programs for unique applications such as home health nursing
and case management

Documentation of client status and medical record keeping

How might a computer assist individual nurses with their daily
activities? In the typical day of a nurse providing direct client care, as
much as one third of the time may be spent recording in the client’s
record. Additional time is spent trying to access data about the client
that may be somewhere in the medical records or elsewhere in the
health care agency. Nurses need access to standardized forms, policies,
and procedures. Also nurses need to be able to gather broader client
information such as length of stay for specific diagnoses. Computer can
assist with each of these tasks.

BEDSIDE DATA ENTRY

These are several different types of compauterized bedside data entry
systems. These allow recording of medication administration.

This screen shows a MAR (medication administration record) for several

regularly scheduled and prn medications. The worksheet displays the
next time the medication may be administered.
The nurse uses a handheld reader to scan the bar code on the client’s
identification band to prior administering medications and other
treatments
The nurse is using a laptop computer to record data at the client’s
bedside
The screen displays the client’s vital sign. They can be entered by the
nurse or anyone with the security rights to do so at the bedside and
displayed whenever needed.

One of the strengths of an electronic health record is its ability alert the
clinician to potential adverse drug
Numerical route can be graphed to show findings.
Client undergoing an electroencephalogram (EEG), a graphic record of a
brain’s electrical activity.

The nurse wears headphones as she listens to and records a client’s

heart rate using a home telecare device. A growing number of health
care providers are using video monitoring to check in on clients.