The process of adopting Electronic health records over paper charts is a continuous process. Although many organizations have already converted at 100%, many have not done so. Some benefits with using EMRs include having accurate and complete information about patients when pertaining to H&P, enabling safer prescribing, it promotes legible documentation, and reduces costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health (Health IT, 2019). According to Kruse et al. (2016) some barriers include cost, technical support, technical concerns, and resistance to change. Due to cost being a continuous barrier for adoption in some situations, the government offers incentives to those who adopt EHR systems instead of paper charts. When pertaining to H&P, some barriers included not having enough time to chart all that is required in electronic charting as well as inability to input historic medical record data easily (Kruse et al., 2016). When pertaining to APRNS, the use of EHRs can hinder patient interactions since APRNs need to document in real time, as well as hinder care if an APRN has issues ordering a prescription or referral (Balestra, 2017). Some ethical issues are also noted for APRNS with the use of EHRs due to the risk of HIPAA violations if APRNS are not careful with their login information. Legal issues arise with EHRs due to the possibility of copying and pasting notes, use of templates that create a note without thorough input of the APRN, late entries and changes, and failure to documents or having incomplete/inaccurate documentation (Balestra, 2017). With all the examples mentioned, it is important to note that as EHRs become the dominant form of charting, new providers need to ensure that they do not get comfortable with templates by double checking their work to prevent medical, legal, and ethical issues.
Healthcare has made advancements from paper charting to electronic medical records. H&P documentation is the most formal and complete assessment of a patient and underlying health problem. Adopting EMRs in H&P documentation involves benefits, challenges, and barriers. With the availability of EMRs, health information can be exchanged and retrieved electronically, facilitating the delivery of high-quality care (Heart et al., 2017). One major benefit of EHR is that is it easily accessible. The multi-disciplinary team involved in the care of a patient can access the patient’s chart at different times and easily view the patient’s medical history, current medications, and treatment plans which allows a provider to plan the course of care more efficiently. Medical errors are reduced since EMR systems provide accurate, updated, and complete information about patients, including past medical therapies. In this case, a physician finds it easy to deliver care based on past medical history. It eliminates the problem of lost patient records in the manual records. Additionally, EMRs facilitate communication and engagement between the patients and physicians and allow engagement between physicians (Heart et al., 2017). As a result, care delivered usually involves the patients and consultations between clinicians, leading to improved care. Moreover, the accessibility of patient information is quicker, facilitating efficient and coordinated care. For example, different providers can retrieve patient data in different locations, which can be lifesaving, especially in critical conditions. Finally, a safer and more reliable prescription is ensured by adopting EMRs systems in H&P documentation.
Despite the broad advantages of the documentation of patient records, EMR adoption is faced by several barriers that slow down the adoption process on the fully integrated EMR systems. For instance, litigations and legal complications. Before transitioning EMR systems, organizations must identify and dedicate appropriate administrative and medical staff to implement them. Poor implementation can increase errors, exposing the clinicians to potential malpractice lawsuits and other legal complications. Second, increased risk of medical errors is another barrier to the adoption of EMR systems for H&P documentation which could discourage some health facilities from implementing these EMR systems. Finally, high implementation costs involved also prevent the adoption of EMR systems (Heart et al., 2017). These costs include purchasing the system, customization, maintenance, and training costs.
The adoption of EMRs also involves some challenges. For instance, physician burnouts are common due to the burdensome user interface. As a result, the overall physician output is impacted due to stress leading to decreased quality of care and less time to attend to patients. A study by Tajirian et al. (2020) presented, from the sample size, 25.6% of practicing physicians and 19% of learners reported having one or more symptoms of burnout, and 74.5% of all respondents who reported burnout identified EHR a reason. Another challenge experienced with utilization of EMR is that interoperability is experienced. To ensure accurate representation of patient medical data, systems must communicate effectively. However, a lack of interoperability between systems negatively affects the utilization of EMRs (Heart et al., 2017). Finally, storing sensitive data in the cloud just like most EMRs do increases the risk of hacked patient information, resulting in loss or alteration of records.
APRN documentation is primary source of evidence and reflection of events that occur during service delivery. Hence, the documentation should be factual, consistent, and accurate. It should be reflective of any encounter, significant event, discussion with patients regarding laboratory/imaging tests, referrals for consults, medication lists, and education materials. Objective terms are mandatory, and assumptions should be avoided. Clear, accurate, and accessible documentation is essential to provide safe, quality, and evidence-based care. As mentioned by Nkechi (2021), one of the principles of legally defensible documentation is “adherence to organizational policy and procedures, standards of care, guidelines, competencies, and any other organizational document that guides the care of patients.” Hence, inaccurate and incomplete documentation can lead to negative outcomes, including putting providers and healthcare organizations at risk of liability.
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