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The purpose of this pilot project was to track the electronic health record documentation of pressure ulcers on a medical-surgical unit and compare the electronic health record with the written medical record.
Adoption of the electronic health record (EHR) has increased in the United States to approximately 17% and continues to rise steadily (Poon et al., 2010). Nursing documentation has shifted from the written medical record to the EHR because its use is beneficial to health care quality and safety. Basic EHR systems have been defined by the Institute of Medicine (2003) as:
(1) A longitudinal collection of electronic health information about a person, or healthcare provided; (2) immediate electronic access to a person or population level information by authorized users; (3) provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and (4) support of efficient processes for healthcare delivery. (p. 1)
Throughout health care facilities, various forms of EHR systems have different functions. Most EHRs represent medical concepts that form the content area and are based on professional nursing organization standards, regulatory requirements, and other evidence-based practice (EBP) sources. EHRs rooted in EBP have eight core functions: decision support, health information and data, results management, order entry, electronic communication and connectivity, patient support, administrative processes, and population health management (Jamal, McKenzie, & Clark, 2009). An EHR refers to an information repository in which patient data are stored in digital form. It contains retrospective, concurrent, and prospective information, and its primary purpose is to support continuing, efficient, integrated quality health care. The combination of structured data and the development of a robust national vocabulary delivers a consistent representation of what providers do during the delivery of health care. Standardized documentation allows the use of data from EHRs to learn about health care, preventive actions, and outcomes of nursing interventions. Moreover, EHRs can facilitate communication between health care professionals (HCPs), promote safety, reduce costs, and facilitate EBP (Poon et al., 2010; Wrenn, Stein, Bakken, & Stetson, 2010).
The template in the EHR can allow physicians and other HCPs to see the information they most need. Also, documentation takes less time. Description about patient assessment results is one advantage of the EHR. Another advantage is improved communication among HCPs be...