electronic health record (EHR) Response#2

Respond to your colleagues’ posts by sharing your thoughts on their specialty, supporting their choice or offering suggestions if they have yet to choose. 

At least 2 references in each peer responses!

Having been an RN in a few different countries, namely the Philippines, Jordan, Saudi Arabia, and Canada, impacted how I evolved as a nurse in the 21st century. Starting as an RN in a third world country 13 years ago was challenging. Instruments in the operating room, as well as gloves, were reusable through the process of autoclaving. Patients documents were hand or typewritten and attached in a solid steel frame chart. In far-flung areas where hospitals are out of reach, people die of myocardial infarction and infectious diseases due to the lack of resources. There is available transportation, including an ambulance; however, there is the absence of an AED or life-saving medications and providers to treat a disease. Besides, the travel takes at least 3 hours to arrive in the hospital. That is the reality of my hometown in the Philippines.

As I ventured along as a nurse in the Middle East, I was amazed at a national system of government-funded health care and how technology evolved. I practice how to use computer-based electronic health and utilized advanced technology in my daily patient care encounter. However, the electronic health record didn’t have much of the options in transmitting data compared to the electronic health record (EHR) that we have today. Those days, the usage of a computer was to record nurses’ notes, input records of vital signs, and check laboratory and imaging results of the patient. In today’s world, we can see competitions and evolving EHR in hospitals. Nowadays, several hospitals and health systems with mature EHRs have portals for patients to access and record their health data. (Glassman, 2017).

We are now in the future of involving patients in their care. I got awestruck with telemedicine and hospital bill payment transactions through hospital portals. Globally, the spread of information in several countries in the hospital setting evolved tremendously. Saudi Arabia’s government spends thousands to millions of dollars to develop and improve the kingdom’s health care through research and technology. King Faisal Specialist Hospital & Research Centre (KFSH&RC) is Saudi Arabia’s first integrated digital hospital that successfully utilized superior health information technology upon achieving Stage 7 on the ambulatory Electronic Medical Record Adoption Model (EMRAM). Alswailem(2017).

Before my arrival in the US, It was part of my obligation to do a 16-week online course in Health Stream as part of my transition in the US nursing practice. It is a great advantage to re-learn basic nursing principles using animations and online patient simulations. I also learn about the problems of miscommunications in the hospital setting due to the use of abbreviations. All health care settings should create a plan for implementing an ANA recognized terminology supporting nursing practice within their EHR. (American Nurses Association, 2018).

Interestingly, I find out that few of my colleagues still utilized abbreviations like U, IU, QOD, and other more. I realized that there is still discrepancies and incongruencies with the abscense of nursing informatics whose role is to facilitate clinical care, education, administration and research. (Darvish, Bahramnezhad, Keyhanian, & Navidhamidi, 2014).

Indeed, it is essential to be aware that a standardized nursing language should always be carried out. This will enhance better communication among co-workers, increased visibility of nursing interventions, improved patient care, enhanced data collection to evaluate nursing care outcomes, greater adherence to standards of care, and facilitated assessment of nursing competency. (Rutherford, 2008). In the future, we may be able to defend ourselves if a quantitative or court review comes knocking on our doors.