Nursing Best Practices in Electronic Health Records

Advancement of Technology in Healthcare

Today, healthcare system has become dynamic such that advancement in technology plays a crucial role not only in nursing work but also in education of nurses. Thus nurses that are equipped with skills, knowledge as well as attitudes does not only create but also deliver experiential encounters in their learning which ultimately enhance reflective practice as well as consequently leads to measurable outcomes especially in patient safety. According to Cashin and Cook (2010), Informatics integration with EBP (evidence based practice) is essential in the achievement of data transformation for improving patients’ care, security as well as privacy. Thus application of technology knowledge may assist in early identification of potential problems (Samadbeik, Gorzin, Darvish, Bahramnezhad, Keyhanian, & Navidhamidi, 2014). For instance, electronic documentation usage may help in the identification of changes in the status of a patient which can quickly happen since the information is well stored as well as readily available.

Importance of Nursing Best Practices

Healthcare excellence is not only dependent on nursing best practices but also it is important to note that nurses require best practices in daily routines. According to McGonigle, Hunter, Sipes, and Hebda (2014), communication is regarded as one of the best nursing best practices. Essentially, communication plays a crucial role in shift change which comprise; handover, sign-out, shift report, handoff, and cross-coverage. Besides, it is imperative to note that during shift change only accurate as well as complete patient information is not only recorded but also transferred effectively.

Ensuring Patient Safety through Nursing Best Practices

A successful handoff is considered to occur when a patient’s care is not interrupted due shift change of nurse-to-nurse mistakes. However, in circumstances that shift change mistakes like inappropriate handoffs occurs, patient care can face problems such as surgery mistakes, incorrect medications or even fatalities due to inappropriate communication breakdown as well as omission of important patient information especially on sign-out sheets. Throughout shift change, full and proper staff coverage is not only important but also ensures that nurses are not distracted which ensure that only accurate as well as up-to-date documentation of patients are submitted and there exist a room for asking questions. Furthermore, verification of patient information whether electronically stored information or paper work by on-duty nurse is supposed to be read back to the nurse at the end-of shift.

Evidence-Based Infection Control

Furthermore, nursing best practices that are useful in combating infection spread commonly known as evidence-based infection control comprise of standard procedures of care such as decontamination, hand hygiene, antibiotic stewardship as well as barrier protection. Ethically, nurses need to perform hand hygiene after patient interaction whether they are using electronic devices or not and when exiting or entering rooms of patients. Protection barriers are namely gowns, wearing gloves, goggles and masks. On the other hand, room as well as equipment decontamination is necessary in the prevention and reduction of the spread of infections. Also, the importance of antibiotic stewardship is in stopping treatment overuse.

Nursing Best Practices in Documentation and Ethical Responsibilities

In any health organization or setting, nursing language standardization facilitate acceptance of documentation of new approaches especially in relation to electronic health records. Besides, in daily nursing routes, nursing notes template is considered as one of the helpful methods. In addition, usage of template is useful as a reminder of crucial patient care documentation information. Furthermore, according to RNAO (n.d.), the standards as well as best practices of a nurse as articulated by ethics include promoting justice, providing safe, competent, compassionate as well as ethical care, preserving dignity, being accountable, and maintaining confidentiality as well as privacy of patients. Thus nurses develop best practice by abiding by the nursing ethics and standards since practice standards do not only help nurses to make appropriate decisions but also understand effectively their responsibilities which eventually results to better care.

Role of Nursing Leadership in Health Informatics

The diversity as well complexity of health care systems today makes nurse leaders to utilize information as a tool in making decisions as well as a crucial element in reflecting future preferred effective, informed and sustainable healthcare. Besides, nurse leaders do not only equip themselves with trending nursing informatics skills of management such as information management competency but also position themselves to reap the EHRs (electronic health records) benefits (Samadbeik, Gorzin, Khoshkam, & Roudbari, 2015, p. 41). In health facilities like LTC in Bronx, New York; nurse leadership has moved transformative practice through EHRs successful leverage which ensure that timely, informed, as well as knowledge driven decisions are made thereby delivering sustainable healthcare. This is because a proper adoption of EHRs increases accessibility, portability as well as readability thereby ensuring effective data sharing of patient’s records.

Confidentiality and Data Security in Electronic Health Records

However, since electronic records have become simple to transfer or distribute chances of patient confidentiality breaches has increased. Actually, data security refers to the system protection of patient as well as hospital data from malicious use or accidental access, disclosure, modification or destruction. On the other hand, confidentiality refers to the protected information of a patient such as future, past or present basic identifiers of mental or physical health conditions, health services provisions as well as services payment. Confidentiality as well as privacy of patients is a basic right in the society thus safeguarding them in relation to a patient’s health information is not only ethical but also a legal obligation that health care professionals must respect.

Regulatory Bodies and Patient Information Privacy

Electronic health information regulatory bodies are namely; the Healthcare Information and Management Systems Society, the National Cyber Security Alliance, the Department of Health and Human Services. Besides, HIPAA (the Health Insurance Portability and Accountability Act) also guarantee security as well as privacy of medical identity and health information protected. HIPAA privacy limits the access of patients’ health information as well as how information can be used. Health professionals and the hospitals may only use a patient’s information for purposes such as treatment, specific operational purposes, obtaining care payment. Nurses have to abide by the regulatory requirements to thereby ensuring that they respects and understands the necessity of patient confidentiality as best practice in nursing as a career.

Patient Safety and Quality Improvement Act

Patient Safety and Quality Improvement Act popularly known as PSQIA, enhances data availability to resolve as well as to assess a patient’s health care, safety and quality issues through establishing a system of voluntary reporting. Besides, PSQIA ensures there is a federal confidentiality protection and privilege for patients’ information safety. Furthermore, HHS (Health Information Privacy) is authorized by PSQIA to impose penalties in terms of civil money for violations of confidentiality of patient safety (The Department of Health and Human Services (HHS), 2017). These and among other supports that PSQIA provides ensure that the confidentiality of patient information are protected thereby promoting patient outcome.

Importance of Meaningful Use in Nursing

In conclusion, meaningful use is associated with EHRs (electronic health record) usage in a meaningful manner. Besides, meaningful use also incorporates electronic information exchange as well as clinical quality measures submission. Thus nurses need to be competent in areas such as retrieval, storage, collection and date usage, knowledge and skills to ensure that patient care is effective.

References

Cashin, A., & Cook, R. (Eds.). (2010). Evidence-based practice in nursing informatics: Concepts and applications. Hershey, PA: IGI Global.

Khoshkam, M., & Roudbari, M. (2015). Managing the Security of Nursing Data in the Electronic Health Record. Acta Informatica Medica, 23(1), 39-43.

McGonigle, D., Hunter, K., Sipes, C., & Hebda, T. (2014). Why nurses need to understand nursing informatics [PDF]. AORN Journal, 100(3) 324–327.

RNAO. (n.d.). Standards and best practices | Careers in Nursing. Retrieved from http://careersinnursing.ca/new-nursing-and-students/becoming-registered-nurse/standards-and-best-practices

Samadbeik, M., Gorzin, Z., Darvish, A., Bahramnezhad, F., Keyhanian, S., &Navidhamidi, M. (2014). The role of nursing informatics on promoting quality of health care and the need for appropriate education. Global Journal of Health Science, 6(6), 11–18.

The Department of Health and Human Services (HHS). (2017, June 16). Patient Safety and Quality Improvement Act of 2005 Statute & Rule. Retrieved from https://www.hhs.gov/hipaa/for-professionals/patient-safety/statute-and-rule/index.html