Introduction

Technology in the healthcare sector is constantly developing and improving. To enhance patient outcomes and ensure patient safety, computer-based solutions are being used by many healthcare facilities to guarantee security, effective care, and improved quality (Meeks et al., 2014). Every day, we get a tremendous amount of data from our patients, including their assessments, clinical information and any changes, allergies, previous medical histories, and other health-related data. It can be challenging to keep up with this. We can ensure improved time management and real-time updates of our patient’s medical information by using electronic medical records (EMRs) (Vaghefi et al., 2016). Before EMRs, the only way we could keep track of medical records, documents, doctors’ prescriptions, and patient history was by use of handwritten paper charts. Human errors like incorrect spelling, transcription errors, and different terminologies can make this a problem.

Advantages and Disadvantages of EMR

Advantages

The use of EMR has brought up many advantages. EMRs can be accessed from any secure computer anywhere in the healthcare facility. It lets providers view real-time updates to evaluation data, lab results, intervention implementation details, and other information (Vaghefi et al., 2016). Many benefits can be recognized when switching from handwritten to electronic charts because human error is a concern. With current physician instruction, EMRs lessen the likelihood of reading unreadable handwriting, potential misunderstandings of medical language, or incorrect medicine delivery.

Disadvantages

Similar to every new technology or implementation, there are drawbacks to EMRs. EMRs need training to be used appropriately; this training can be expensive, time-consuming, and stressful for employees to complete (Vaghefi et al., 2016). Finding the information we require might be challenging if we are unfamiliar with the processes, which is why training is crucial. Patient Safety Presentation Discussion Paper The transitional period to electronic charting is another issue. When moving from paper to electronic, information may be lost or corrupted. The handoff could be made more complicated if the chart is available in various versions simultaneously, putting some of our most vulnerable patients in danger. This poses a threat to our patient’s safety and quality of care, which makes it unsafe. Due to cybercriminals, technology, in general, might be risky. These cybercriminals are capable of breaking into the system and releasing private data.

Additionally, there is a risk that information could be stolen from a computer or accessed by a criminal using an unencrypted device (Vaghefi et al., 2016). By modifying EMR software with anti-malware software to protect patient information, we can help lower the likelihood of a breach. This method can reduce considerably lower the danger of a breach; however, it is not secure.

Legal Implications

Legal implications must be dealt with when switching to electronic records. The fact that healthcare providers cannot review all the data in patient records raises legal issues. This might result from EMRs’ infinite data storage and readily available records that detail every patient’s care, regardless of when or where it was provided. Due to information overload brought on by this enormous virtual data set, essential insights may be missed (Meeks et al., 2014). As healthcare professionals, we may be held accountable for seeing illegal patient information, which has another legal implication. This immediately impacts the privacy of the patient. Each access to data and information is recorded by EMRs, allowing them to determine whether the user was permitted or whether they missed reviewing essential data.

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Ethical Implications

There are records of healthcare personnel who have access to data about patients selling that information to health insurance firms (Vaghefi et al., 2016). Clinicians must notify patients of any data breaches and take precautions to prevent any data breaches involving patients (Meeks et al., 2014). Although it is suitable for a patient to access any of their health records, there have been cases of various EMR suppliers selling copies of their customers’ data that have been de-identified. Human-error incidents occur mistakenly when information is left exposed for public inspection because a medical professional had to leave for an emergency or acted carelessly.

Patient Safety Outcomes

As healthcare professionals, we aim for patient pleasure. Unsafe conditions that raise the risk of a safety event, adverse incidents that affect the patient, and near misses that do not affect the patient are all considered patient safety concerns (Meeks et al., 2014). We may view the medicine administration records (MAR) in the EMRs. The MAR contains alerts, reminders, and signals for improper dosages to prevent mistakes. Patient Safety Presentation Discussion Paper Along with alarms and reminders, MARs can identify patients likely to experience a medical reaction, indicate any changes in patients who require immediate attention, and assist in facilitating early and compelling therapies. Systems for entering prescriptions make use of information on the patient’s diagnosis, any medications they are currently taking, and any allergies or drug interactions they may have had in the past. All of this contributes to a reduction in improper prescription orders. The advantages of electronic medical records exceed the drawbacks by a wide margin. They have repeatedly shown what a valuable asset they are to healthcare professionals. They have done so much more, including lowering the number of prescription errors, assisting nurses in staying on task, enabling caretakers to access any information from anywhere in the facility, and more. In the medical industry, time is always of the essence. A patient’s life could be saved instantly thanks to the accessibility of EMRs from anywhere at any time.

Impact on Professional Nursing

The application of electronic medical records (EMRs) has profited most from technological improvement. They can enhance patient safety, healthcare quality, and general health outcomes. There are indicators when a prospective drug interaction, allergy, or overdose exists. They also enhance communication between patients, medical professionals, and others involved in their care (Meeks et al., 2014). The risk of misreading an instruction is one of the best things an EMR does. Illegible handwriting or ambiguous orders are a thing of the past because everything is computer-based.

Last, it does away with verbal orders, leading to misunderstandings and incorrect hearing. Nearly all elements of the nurse-patient relationship and interactions with other parties significantly contribute to EMRs. It can improve the unit’s workflow and offer safety and better communication. However, as technology develops and humans adjust, they must accept the changes. Some individuals think that EMRs can impede this process.

Compared to handwritten paper charts, electronic medical records have benefits. Multiple nurses, doctors, and other healthcare professionals can chart the same patient at once, attributable to EMRs (Meeks et al., 2014). Since this is done in real-time, there is no need to question if the patient data is current. Each nurse responsible for the care will chart in order at any given moment or throughout any given shift. In order to make sure that the correct orders are being followed, the chronology of patient charting assists in painting a picture of the treatment the individual is receiving and at what time. A shortcut for solely noting unexpected findings specific to that patient is to chart by exception.

Conclusion Reflection

Access to health information technology must be facilitated for vulnerable people; thus adjustments must be made. Healthcare could be improved by having better access to patient data from various sources at the point of care: detailed patient data can support the best decision-making; accessibility to modern diagnostic tests can reduce duplicative testing; improved medication knowledge can improve patient satisfaction; detailed pictures of patients’ care trends can improve coordination of care. The majority of nurses ought to support the usage of EMR. EMRs achieve the objective of keeping our patients safe.

At the point of care, EMRs offer precise, current, complete, and real-time patient records. They can securely share the information with the patient and other parties involved in their care while also making it simple to enable quick accessibility of patient records quicker for more coordinated, high-quality care. EMRs assist healthcare professionals in making accurate diagnoses, lowering medical errors, and delivering safer care. If we can use EMR to enhance patient-provider-nurse engagement, communication, and ease of access to health care, we can significantly increase patient safety and the efficacy of care. It is genuine that EMR aids in enabling safer, more dependable prescribing, promoting legible, complete, and proper documentation, enhancing patient data privacy and security, enhancing productivity and work-life balance, as well as aiding in cost-saving measures by reducing paperwork, enhancing safety, minimizing duplication of testing, and enhancing both staff and patient general wellbeing.

References

Meeks, D. W., Smith, M. W., Taylor, L., Sittig, D. F., Scott, J. M., & Singh, H. (2014). An analysis of electronic health record-related patient safety concerns. Journal of the American Medical InformaticsAssociation, 21(6), 1053–1059. doi:10.1136/amiajnl- 2013-002578

Vaghefi, I., Hughes, J. B., Law, S., Lortie, M., Leaver, C., & Lapointe, L. (2016). Understanding the impact of electronic medical record use on practice-based population health management: A mixed method study. JMIR, Medical Informatics, 4(2). doi:10.2196/medinform.4577