Nursing documentation is an important part of nursing practice. Studies have shown that 50% of each nurse’s time at work is used for documentation. The patient’s notes are used for various purposes like communication between health professionals, compensation by Insurance, medical research and education, and legal evidence in courts of law. This requires that the patient information be easily accessible, and at the same time remain confidential. The International Council of Nurses (2012) requires nurses to ensure that they maintain confidentiality with patient information and when sharing is required, they should use ethical judgment.
The methods of handling patient information have evolved over time. The use of paper has now been replaced with other methods such as electronic medical records which are a digital version of patient information that was previously written on paper and patient files. The use of electronic medical records was pioneered by former USA president George Bush. President Barrack Obama in 2009 increased the funding to support the use of electronic medical records. The Maryland University hospital is one of the hospitals that adopted this method of handling patient information.
The hospital has a local network where all their employees who are allowed to access patient information have passwords for their portal. Every patient has a page that can be accessed using the patient’s hospital number or the social security number. The different professionals can add inputs to the patient’s charts. Laboratory technicians can input the patient’s results and the physicians can input the patient’s prescriptions. Once input has been done, it becomes available to any other person who accesses the site while the primary nurse can access the information a short while later.
The benefits of this method of handling patient information have been numerous. First, it allows one to store a lot of data on an individual which can be stored easily and retrieved when required (Simpson, 2005). It has been thought to reduce errors in the medical field and the costs of documentation and sharing of information (Fuller, 2009). There have been problems previously with trying to decipher what someone wrote in a patient’s record. This problem has been solved with electronic records. In addition, there are no risks of the papers wearing out and being illegible with time.
The use of electronic medical information has its problems since its adoption at the hospital is not clear when or how the information should be discarded. Electronic records can store information for years since the point at which a patient’s page should be deleted from the system is also not clear.
The availability of the information to anyone who has access to the system anytime and anywhere poses a risk for confidentiality. The information can be accessed by unauthorized persons who manage to hack into the system. There are several organizations whose websites have been accessed by hackers and confidential information has been leaked to the public and the hospital is not immune to this issue. They are also at risk of hackers who may want information about the patients. The International Council of Nurses (2012) code of ethics requires that the information management systems used to document patients’ information maintain patient confidentiality.
The electronic medical records system minimizes errors but does not completely avoid them. Errors may occur when one is entering data about a patient into the system. This data may be entered wrongly and may result in risking the patients’ lives. It has also reduced verbal communication between health care providers. In the past, a physician would write a prescription and inform the nurse by word of mouth that he has written it and the type of medication to be administered. Electronic records have reduced this interaction and this puts the patient at a higher risk as there is no consultation and discussion of the ideal treatment.
A data breach has been on the rise in the USA. It is actually difficult to read a newspaper and miss information on a data breach that occurred (Lapidus, 2008). Organizations need to know that their data may be breached and be prepared to handle it when it happens. The organization should have security assessments that take place within the company to protect its systems from hackers.
The hospital should also have in place an internal breach response team. This includes a wide number of professionals like operations staff, legal advisors, and communicators. Many organizations train their operations staff how to hack into systems so that they can be aware of how prospective hackers can hack, and thus they solve the problem before it occurs. The legal advisors will serve to protect the organization in the case that the organization is sued for such occurrences (Lapidus, 2008).
Medication errors are a big problem in the USA and the world at large. Electronic medical records can only reduce medical errors if the data input is done correctly. One way of minimizing errors is the use of personal health records (Agrawal, 2009). They also involve patients in managing their own health as the patients have access to their own information. Patients are also involved in the reconciliation of their medication and they are able to know exactly what they are taking. Thus, it provides patients with the opportunities to know which drugs they are allergic to and avoid them.
It is evident that the electronic medical records system has added a lot of value to documentation in the medical field. It has improved communication and accessibility of information like lab results. Hence, one does not have to walk to the lab to access results but can easily access them online. To a greater extent it has reduced medical errors that have been a major problem in the medical field. The accessibility of information has enabled research on health trends to be easily done as data is easily available.
The use of electronic medical records has several benefits but it also has various problems such as data breach and errors that have been discussed above. Other problems with information technology systems such as viruses may be problematic. This requires that all organizations employ highly qualified professionals to deal with these problems when they occur. Nonetheless, the benefits of having an electronic system outweigh the risks. This is the reason why the government and organizations are investing a lot in ensuring that the implementation of this system is a success.
The system has faced other problems such as the professionals not being able to adapt to information technology and blend it with their careers. Doctors have complained that the system has made their practice slower than it was. They are able to see only half of the patients who they usually see. This has led to the development of course units specifically to blend information technology and the practice of nursing. This will hopefully ensure a successful adoption of information technology in the management of health information.
References
Agrawal, A. (2009). Medication Errors: Prevention Using Information Technology Systems. British Journal of Clinical Pharmacology 67(6), pp. 681-686.
Fuller, D. (2009). Challenges in Nursing Informatics. Web.
International Council of Nurses. (2012). The ICN Code of Ethics for Nurses. Web.
Lapidus, B. (2008). Responding to a Data Breach: Communication Guidelines for Merchants. Web.
Simpson, L.R. (2005). e-Ethics: New Dilemmas Emerge alongside New Technologies. Nursing Informatics, 29 (2), pp179-182.