Keiser University Clinicians Issues with Documentation in EHR Systems Paper

3 days ago

Elijah Shaleen

Discussion 5

COLLAPSE

Clinicians have issues with the documentation and seeing exactly when to determine the time frame for medical intervention. This an happen when dealing with 2 different EHR systems or data sources. Things may be documented in one area of the patient’s chart, but not in another and therefore important information could be missing. Some information may need to be documented in more than one place in order to have access to what the physician is truly looking at. This means it should be in the notes area, but also the drug therapy area to see what is or is NOT working. It can also cause problems in the clinical notes stating ‘acute’, when a pathology report may state chronic. This causes a confusion and inconsistency in the record. This can be an inoperability issue.

Another issue is the medications. If a physician enters order for after care or medications, they are not always able to be seen or accessed. This can be a computer glitch. Whatever the case, it can be harmful for the patient to be given the correct medications at the right time. I have actually seen this happen at my place of employment. I’m glad the ‘eyes and ears’ of my facility are very knowledgeable when it comes to knowing their patients, so they bring this to the nurse immediately. I have seen where it is on the pharmacy side sending medication through to the EHR systems at different times than when we have them being administered which poses a problem. Other issues that can happen is the pharmacy may send a double dose of the medication that does not math the EMAR costing time making phone calls to verify what actually is to be done. If the systems do not work together, it is not time efficient and can be a big hassle on the nursing staff, as well as the patient waiting to receive their medications when they are use to having them administered. There can be quirks with EHR systems and I’ve seen it.

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