Introduction:
Electronic health records systems are used in various hospitals, community health settings, and doctor’s offices to enter and view client information. Unique client identifiers are used to ensure that information about the client is linked with the correct health care provider, the client’s most recent results of laboratory and diagnostic tests, and an updated list of currently prescribed medications. Information about the client’s vaccination history, allergies, consults, operative reports, and discharge information is also provided. A benefit of using electronic health records is that health care providers have quick access to medical information. Clients benefit as they receive improved management of chronic diseases, such as when health care professionals can receive reminders of follow-up tests. Electronic health records also reduce unnecessary repetition of laboratory and diagnostic testing, which ultimately saves money. A risk of electronic health records is that people not within the circle of care may access confidential information. Regional health authorities have taken measures to monitor for such risks. These measures include providing limited access and monitoring who is viewing any confidential health information.
Electronic health records may also include the use of standardized evidenced-based protocols for nursing care. Nurses can access the most current evidenced-based protocol to see potential nursing interventions, which can serve to improve documentation of assessments and interventions by providing reminders to chart specific symptoms or to chart the administration of PRN medications.
“Electronic health systems use standardized clinical terminologies so that all health care providers can communicate findings and share client information within their specific practice settings. Standardized clinical terminologies refer to a set of common terms that describe health conditions, treatment plans, and necessary interventions”
Legal Considerations and Ethics
Nurses can be reprimanded or have their licenses revoked for not appropriately following the Nurse Practice Act in the state they are practicing. Nurses can also be held legally liable for negligence, malpractice, or breach of patient confidentiality when providing patient care.
Code of Ethics
In addition to legal considerations, there are also several ethical guidelines for nursing care. There is a difference between morality, ethical principles, and a code of ethics. Morality refers to “personal values, character, or conduct of individuals within communities and societies.” An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness). A code of ethics is set for a profession and makes their primary obligations, values, and ideals explicit.
Electronic health records systems are used in various hospitals, community health settings, and doctor’s offices to enter and view client information. Unique client identifiers are used to ensure that information about the client is linked with the correct health care provider, the client’s most recent results of laboratory and diagnostic tests, and an updated list of currently prescribed medications. Information about the client’s vaccination history, allergies, consults, operative reports, and discharge information is also provided. A benefit of using electronic health records is that health care providers have quick access to medical information. Clients benefit as they receive improved management of chronic diseases, such as when health care professionals can receive reminders of follow-up tests. Electronic health records also reduce unnecessary repetition of laboratory and diagnostic testing, which ultimately saves money. A risk of electronic health records is that people not within the circle of care may access confidential information. Regional health authorities have taken measures to monitor for such risks. These measures include providing limited access and monitoring who is viewing any confidential health information.
Electronic health records may also include the use of standardized evidenced-based protocols for nursing care. Nurses can access the most current evidenced-based protocol to see potential nursing interventions, which can serve to improve documentation of assessments and interventions by providing reminders to chart specific symptoms or to chart the administration of PRN medications.
“Electronic health systems use standardized clinical terminologies so that all health care providers can communicate findings and share client information within their specific practice settings. Standardized clinical terminologies refer to a set of common terms that describe health conditions, treatment plans, and necessary interventions”
Legal Considerations and Ethics
Nurses can be reprimanded or have their licenses revoked for not appropriately following the Nurse Practice Act in the state they are practicing. Nurses can also be held legally liable for negligence, malpractice, or breach of patient confidentiality when providing patient care.
Code of Ethics
In addition to legal considerations, there are also several ethical guidelines for nursing care. There is a difference between morality, ethical principles, and a code of ethics. Morality refers to “personal values, character, or conduct of individuals within communities and societies.” An ethical principle is a general guide, basic truth, or assumption that can be used with clinical judgment to determine a course of action. Four common ethical principles are beneficence (do good), nonmaleficence (do no harm), autonomy (control by the individual), and justice (fairness). A code of ethics is set for a profession and makes their primary obligations, values, and ideals explicit.