Exam 2
1. Understand barriers to electronic health record (EHR) systems.
• Resistance from healthcare providers
• Data security
• Difficulty with data integration
• Difficulty with data exchange between different systems
• Connectivity issues (WIFI)
• Training
2. Discuss the importance and purpose of EHR, including client safety rules.
• Enhance patient care and safety/ improve healthcare outcome
• Improve communication between interdisciplinary teams
• Streamline information decluttering
• Facilitate coordination of care
o Leading to informed clinical decisions
• Reduce medication errors
3. Know the essentials of nursing documentation in the EHR.
• Patient assessment: comprehensive documentation / Vital Signs
• Nursing diagnosis
• Care plans
• Interventions
• Response to interventions
• Patient educations
• Medication administration
• Safety measures
o Fall prevention
o Infection control
• Communication
o Consultations
o Handoffs
• Legal& ethical considerations
• Do Not Document and Incident Report
4. Review Centers for Medicare and Medicaid Services (CMS) guidelines for EHR
management systems.
• Using EHR Effectively
• Sharing Information
o Share patient information easily and securely between different providers and
organizations
• Keeping Information Safe
o Protecting patient privacy
• Keeping Good Records
o Keep accurate record of patient visits, treatments and outcomes
o Helps in reporting quality of care and getting reimbursed
, • Easy to Use