Essay Sample on Electronic Health Records and Standardized Terminologies

Introduction

Documentation and effective communication are essential aspects of nursing. They are not only useful in tracking and recording of patient's information but also improving the effectiveness of clinical services. Just like any other field, there has been an increasing interest in the needs and use of information technologies to improve health services. The use of paper as a documentation tool and verbal communication to exchange information has evolved with time to pave the way for electronic health records, popularly known as EHRs, which is the systematic collection of health information of patients in a population, usually done and stored in a digital form. Despite the setbacks associated with EHRs such as financial implications, confidentiality and security concerns, and a deviation in the workflow, the advantages associated with it makes it sustainable. Electronic health records coupled with standardized terminologies in nursing practice are the most valuable developments of the 21st century. Therefore, use of electronic health records and implementing standardized languages has brought about a whole lot of benefits in nursing -- besides improving the patients care, standardized terminology will help establish a body of evidence-based results in the field of medicine.

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Electronic health systems have proved to be useful and pose a wide range of clinical advantages, which is not possible through the use of paper documentation tools and verbal communication processes (Nagle, Hardiker, Mastrian, & McGonigle, 2009). Unlike paper documentation, the storage of EHRs is in a digital format. Therefore, it does not require large storage spaces for storing large files in hardcopy formats. The use of paper documentation would mean that large cabinets and safes need to be used to store the documents. There are easy management and retrieval of information in these systems. The clinical data are also accessible easily from any location, provided the systems are linked, at a click of a button. Thus, there is a reduction in time of accessing information. There is a direct impact on the productive time of a medical practitioner and directly improves the service rates since no time will be wasted in doing searches and sorting of files. Imagine a nurse informatics specialist trying to access a folder stored in a massive list of papers, which are arranged and stored by different people in different timelines. As this happens, there is a patient who needs the documented information urgently, and whose life hangs on a balance. Time is a significant factor, and in such cases, due to human nature and the pressure surrounding the whole situation, mistakes are bound to happen. The EHRs efficiently assists in avoiding such scenarios. The digital data in EHRs creates an opportunity for interactions between hospitals, labs, pharmacies, and clinics as they can be easily shared as opposed to the paper documentation tools. This aids in research and scientific developments. The ability to research, analyze and gather information on the patient is improved. As a result of this, there are reduced medical errors, thereby increasing the safety of the patients. Thus, electronic health records play an essential role in saving time, and space, reduce errors and increase accessibility of information, which are vital in nursing, thereby improving service delivery and protects life, which is the main aim of clinical services.

Standardizing nursing terminologies has created a milestone in nursing as it helps to capture, represent, and communicate nursing information in a concise way. The standardized nursing terminologies helps in improving communication among health providers. Disclosure of information is critical, and the accuracy with which the information is laid out, especially in a crucial field such as medicine, need consideration. There is improved patient care brought about by nursing terminologies because of the improved collection of data that is used to evaluate nursing care results. Standardization of nursing terminology also brings about a high adherence to set standards of health care due to ease of assessment. According to McGonigle and Mastrian, there has been a more straightforward assessment of nursing competency (Nagle, Hardiker, Mastrian, & McGonigle, 2009). The standardization has made it possible to facilitate regulations. Hence, standardized terminologies have created standard terms or a universal language which has brought about the benefits of ease assessment, adherence to standards and improved patients care in general.

Improved patient care is the ultimate result of standardized terminologies in nursing. Improved communication, which is one of the goals of standardized language, creates an avenue to enhance the quality of documentation involving nursing diagnoses. According to McGonigle & Mastrian, if the information on diagnoses, patient outcomes, and nursing interventions are available, analyzed and stored regularly, it can be a useful tool in enhancing the quality and welfare of patient care. The information enables identification of best and desirable practices, and at the same time, eliminate bottleneck practices, which are hard to identify. Thus, standardized terminologies will directly improve patient care by improving the quality of documentation (Nagle, Hardiker, Mastrian, & McGonigle, 2009).

Nursing terminologies are a critical tool to capture and store information. The information represented in this form can, later on, be accessed and used as nursing practice information, what is generally known as evidence-based results. Advancement in the science of nursing depends entirely on practiced-based knowledge, which is made available from the evidence-based outcomes of nursing terminologies. The standardization makes it possible to research the value and effectiveness of nursing care since standardized languages improve communication. The American Nurses Association, which is a professional body established to protect nursing profession, and has been in operation since 1896, has approved up to thirteen standardized nursing terminologies by now (Nagle, Hardiker, Mastrian, & McGonigle, 2009). They have helped support nursing practices through these terminologies in various ways. Therefore, standardized nursing terminologies are crucial in evidence-based data which have many benefits in nursing science.

Conclusion

Finally, electronic health records, together with standardized nursing terminologies are the most important recent development in the nursing practice. We cannot overemphasize the benefits that accrue from these. The paper documentation tools and verbal communication may have low overhead costs associated with them, and the change from these paper documentations maybe affect the standard workflow. However, they tend to be expensive in the long run. Electronic health records have helped reduce the amount of time, space and cost used in storage and sorting of patient information, which is vital in nursing. Standardization of terminologies has made it possible to create a body of knowledge or codes of operations in nursing. It has brought about ease of information sharing. There has been an integration of the whole sector because of the sharing. Interactions between labs, clinics, and hospitals have also increased tremendously. There is easier evaluation of nursing practice as a result of standardization of terminologies.

References

Nagle, L. M., Hardiker, N., Mastrian, K., & McGonigle, I. (2009). Information and knowledge needs of nurses in the 21st century. Nursing informatics and the foundation of knowledge, 133-146. http://ebooks.iospress.nl/volume/nursing-informatics