Documentation

Introduction
The use of electronic health records and online documentation is beneficial to nursing practice as well as any practice associated with health care. It allows health care providers to promote patient safety and reduce medical errors (Keenan,Yakel, Tschannen, Mandeville) that occur due to poorly and improper documentation, especially on paper. Patient charts, that can be seen through a computer, promotes patient safety due to the fact that a patient's medical record is seen with just one click. Having all of the information their reduces fragmentation when caring or diagnosing a patient (Keenan et al). Having a patient's medical record in one file allows health care providers not to miss any care plans, goals, diagnoses, planned interventions, and projected outcomes (Keenan et al.) that should be included in documentation but is usually left out in paper documentation. In nursing practice, nurses could be introduced to new skills and enhance their knowledge when using electronic health records, which can be beneficial in improving the quality of care for patients (Lee, 2006).

Demo on Documentation through the EMR This demonstartion gives a brief look into how certain aspects of care are documented and specific alerts.

Reporting Adverse Events through EHR This article provides a better insight into the EHR and adverse events. The article dicusses the "use [of] technology to create a new business model that aims at helping physicians better recognize and report adverse events" (Marrill, 2011).

Health History
Health history is an important aspect in the health care setting that is beneficial to health care providers as well as patients. Associating health history with the electronic health record helps promote the safety of patients and the reduction of errors in the diagnosis process. When diagnosing patients, physicians have the capacity to search the health history, from the beginning of the patients medical history to the present time, allowing them to suitably diagnose their health condition and provide better treatment (Potter, 2011). In the times of emergency, having a patient's health history on an electronic health record allows health care providers with easier and faster access to the information, which can be a life saving process (Torrey, 2011). Having an electronic health record allows patients to visit any health care settings because the information about the patient's medical will all be the same (Kleffman, 2009). For example, if a patient is required to visit different health care institutes for their diagnosis, patient's tend to miss important information throughout each institute that will aid in the treatment for their medical illness. When health care providers have all the information from the patient's appointment visits, this allows all the health care providers with the same information, making accurate diagnosis'. Another benefit of having a patient's health history on an electronic health record is when the family history is provided in the patient’s health history allowing health care providers to pinpoint early warning signs and/or symptoms for patients with high risks of medical illnesses (Kleffman, 2009).


 * Case Scenario**

Documentation and Alerts
Before the Electronic Health Record (EHR) every aspect of care was documented on paper; the lab results, notes, and all other documentation had to be looked up in patient files and multiple other sources.The EHR documentations system is used "to facilitate accurate and timely documentation, including evaluating the effectiveness of care, describing patients’ responses to therapy, communicating patient status, and meeting legal documentation requirements”, which will further lead to increasing patient safety (Carrigton, Effken, p.1, 2011).

The EHR has "reduced nurse documentation time, improved legibility, more frequent documentation, and fewer documentation errors than paper-based systems" (Carrigton et al., p.1, 2011). These various aspects of documentation will ehance patient safety and will also allow health care providers to particpate in safe practices. There were high levels of stress in regards to health care providers, especially nurses, remembering to look up everything and document all aspects of care (Kelley, Brandon, Docherty, p. 4, 2011).

Through the use of the EHR, healthcare providers have found that it "[helps] their memory by placing care options in a predetermined drop-down menus that did not require what data elements to chart"; there are also, specific alerts that indicates what care needs to be done, new orders that have been placed and that need to be looked at, and help with identifying changes in lab values (Kelley et al., p. 4, 2011).

__**Case Scenario**__

Discipline Specific Charting
Discipline specific and inter-disciplinary documentation is very important in providing patient safety. Electronic Health Records (EHR) allows health care providers to only document under their discipline; For example putting in new orders is a restricted area of documentation, it is password restricted allowing only doctors to have access. Nurses, also, have specific sections that say Nursing Assessment before each intervention ensuring that each of these health care providers are documenting under the correct headings. Progress notes that have been documented, in the system, indicate whether a nurse, doctor, or other health care provider has inputted them. This ensures patient safety because "physicians, nurses[, and other healthcare providers] collect, record and interpret data during patient care episodes" and document them under the proper headings; if the information is not adequately documented patients care could be compromised (Hayrinen, Saranto, p. 1, 2010). For example, the physiotherapist documents under nursing notes, when the doctor goes to check what the patient had done during physiotherapy they would not be able to see anything documented and care not documented is seen as care not done."The use of standardised documentation [between health care providers] improves quality documentation and retrieval of data from EHR", allowing health care providers to ensure the correct interventions are being implemented and providing patient safety (Hayrinen et al., p. 1, 2010).

Veiwing Dicipline Specific Notes This video shows notes that can be read by health care providers that have been written by various diciplines.