TAILIEUCHUNG - Lecture Nursing documentation using electronic health records: Chapter 1 - Byron R. Hamilton, Mary Harper, Paul Moore

Chapter 1 - An introduction to electronic health records. Chapter 1 content: Brief history of electronic health records (EHRs), history of standards development for the EHR and nursing’s role in their development, certification bodies for the EHR, benefits of the EHR, government involvement in the EHR, role of nursing informatics in healthcare. | Chapter 1 An Introduction to Electronic Health Records © 2012 The McGraw-Hill Companies, Inc. All rights reserved. McGraw-Hill Chapter 1 Content Brief history of electronic health records (EHRs) History of standards development for the EHR and nursing’s role in their development Certification bodies for the EHR Benefits of the EHR Government involvement in the EHR Role of nursing informatics in healthcare . The EHR History . The EHR History Impetus for development Quality patient care 1960s First EMR programs First electronic databases . The EHR History Terms and Definitions CPR: Computer-Based Patient Record EMR: Electronic Medical Record EHR: Electronic Health Record CCD: Continuity of Care Document PHR: Personal Health Record . The EHR History Point of care documentation Modes of Data Entry Keyboard Voice recognition Handwriting recognition Templates and data selection Touch screens COWs/WOWs . The EHR History Security and

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• Nursing documentation
• Electronic health records
• Nurse note documentation
• Fundamental documentation
• EHR history
• Development of EHR standards
• Nursing diagnosis
• Nursing outcomes
• Nursing practice
• Medication administration
• Patient education
• Nursing diagnoses
• Nursing interventions
• Essential documentation
• SpringCharts features
• Routine documentation
• Internal messages
• Chief complaints
• Nurse note components
• Recording vital signs
• Documenting telephone calls
• Ambulatory healthcare
• Ambulatory nurse
• Diagnostic tests
• Nursing Services
• Sensitive Healthcare
• Newcomer Immigrants
• Health Nursing
• Healing Energy
• Professional Communication
• PEG Nutrition
• Documenting Behaviour
• Behavioural Management
• Effective Design
• Incident Reports