PERSONAL HEALTH RECORDS NURS 8210

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In daily practice, health care professionals collect volumes of patient data that vary in type and sensitivity, among other defining elements. As technology use intensifies in health care delivery, electronic health records (EHRs)/electronic medical records (EMRs) have increasingly become a vital component for data storage, retrieval, and sharing. The shift from paper-based to electronic formats has transformed nursing documentation significantly. This discussion explores how EHRs/EMRs have changed nursing documentation of patient care.

Transforming the Quality of Nursing Documentation

The quality of patient care is directly proportional to the quality of nursing documentation. Accordingly, the documentation process must be of high standards. After comparing the process and structure of paper-based health records and EHRs, the electronic formats have been found to have better content input, process, and structure (Akhu‐Zaheya et al., 2018). Here, the implication is that patient data can be stored, processed, and shared in different formats as situations necessitate. Electronic information is also more secure than paper-based records.

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EHRs and Facilitating Efficiency in Documentation

Time is a critical element in health care delivery whose wastage has far-reaching implications on a patient’s health. Generally, EHRs improve efficiency in nursing documentation by reducing the time and clicks used in making an entry. Karp et al. (2019) found that, compared to paper-based documentation, EHRs can reduce time spent in documenting patients’ history by up to 72%. Essential items are also documented appropriately and timely as required. The enhanced efficiency improves clinical workflow proportionately.

Conclusion

Data is crucial in enhancing decision-making in health care, validating patient care documentation accurately, professionally, and conveniently. EHRs have transformed nursing documentation by improving the quality and efficiency of documentation. Nurses can also store and retrieve electronic patient data in multiple formats and when needed.

References

Akhu‐Zaheya, L., Al‐Maaitah, R., & Bany Hani, S. (2018). Quality of nursing documentation: Paper‐based health records versus electronic‐based health records. Journal of Clinical Nursing, 27(3-4), e578-e589. doi: 10.1111/jocn.14097

Karp, E. L., Freeman, R., Simpson, K. N., & Simpson, A. N. (2019). Changes in efficiency and quality of nursing electronic health record documentation after implementation of an admission patient history essential data set. CIN: Computers, Informatics, Nursing, 37(5), 260-265. doi: 10.1097/CIN.0000000000000516

Personal Health Records

Consider the PHRs of today. Patient-accessible health records are currently web-based and have seen little consumer use when compared to the total U.S. population. The VA has had notable success with its veterans logging on; however, other web-based portals have struggled. GoogleHealth, a free PHR site, shut its services down effective January of 2012 citing too few and inconsistent users to maintain the site.

PHRs can eliminate the plethora of patient charts and help to assimilate a lifetime of medical documentation. What do you think will motivate society to fully embrace these electronic resources?

To prepare:

• Reflect on the information presented in the Learning Resources, focusing on personal health records and patient portals as used by the VA.
• Consider your personal and professional experiences with personal health records and patient portals.
• What benefits, concerns, and challenges do these types of systems bring to the health care profession? How might they influence your professional practice and your patient’s health outcomes?
• Explore one patient portal. If you do not have access to one through your practice setting, utilize a free service such as FollowMyHealth https://www.followmyhealth.com/ or Microsoft HealthVault https://www.healthvault.com/en-us/.
• Assess the kind of information that you would put in your own personal health record. What concerns (if any) would you have about the security of your personal information in a personal health record?
• Think about your stance on the value of PHRs. Do you believe that every individual should be required to maintain a PHR?
  • What capabilities and/or features might entice people to use them?
  • What factors might inhibit people from using them?

By Day 3 post a cohesive response that addresses the following:

• Appraise your selected personal health patient portal.
• Evaluate the influence of PHRs on health care delivery and clinical practice.
• Take a position for or against mandating PHRs. Justify your stance addressing the following points:
  • Personal health records via patient portals are part of Meaningful Use 2 and the debate over mandating them is essentially over.
  • What capabilities and/or features might motivate individuals to maintain PHRs?
  • What factors may deter individuals from signing up for this service?
  • What concerns might you and your patients have about a PHR’s capability to securely maintain personal information?
  • How might PHRs influence your professional practice and your patients’ health outcomes, positively or negatively?

Read a selection of your colleagues’ postings.

By Day 6 respond to at least two of your colleagues in one or more of the following ways:

• Select a college whose views are in opposition to yours. Use your research to academically debate why your viewpoint differs from theirs.
• Ask a probing question, substantiated with additional background information, evidence, or research.
• Share an insight from having read your colleagues’ postings, synthesizing the information to provide new perspectives.
• Offer and support an alternative perspective using readings from the classroom or from your own research in the Walden Library.
• Validate an idea with your own experience and additional research.
• Make a suggestion based on additional evidence drawn from readings or after synthesizing multiple postings.
• Expand on your colleagues’ postings by providing additional insights or contrasting perspectives based on readings and evidence.

Return to this Discussion in a few days to read the responses to your initial posting. Note what you learned and/or any insights you gained as a result of the comments made by your colleagues.