Assessment of Clinical Documentation System Functions in My Nursing Workplace Setting

Assessment of Clinical Documentation System Functions in My Nursing Workplace Setting

System and Setting Description

We use Electronic Healthcare Record (EHR) system in our military hospital. It provides various options for clinical documentation to the users of most EHR systems. The EHR system allows for accurate chart information sharing among different users such as our specialists, nurses, labs and pharmacies, and insurers. The structured templates are already created filled in notes for the usual common cases seen by our clinic. It allows us to develop a note that not only provides us with medical report but also stores the data as structured vocabulary. Further, the radio buttons, drop-down lists, and check boxes data entry methods allow us to use various ways for entering structured data. Using EHR documentation system we can also enter data manually as free text in EHR parlance and can type on the keyboard or in some applications by handwriting with a stylus. The modern EHR system also documents the data through voice dictation and transcription. Thus, it incorporates various functions for documentation purpose.

As we used EHR system, it provides thorough and programmed accounting of every patient's medical history. It is being used widely in Military healthcare settings, where it advices physicians on possible risk distinctions in diagnoses like a person has simple cold or COLD (Chronic Obtrusive Lung Disease). As far as EHR system users are concerned, research shows that it is adopted by 55% of physicians (CDC Govt., 2011).

Data Collection and System Analysis

Using EHR system for data collection, we can access and gather all the data from outpatient and inpatient sides and can integrate it. It provides us with the aces of data collection from other military hospitals, wherever the user is based. Thus, the data is collected by multiple site integration from different military hospitals, as if they are all part of a single site.

The data is collected and represented in the form of charts and graphs, flexible ways. For collecting clinical data it the system provides broad continuum free form typed clinical notes to different levels of structured vocabulary and limitation choices.

It provides information to almost all the involving healthcare professionals like nurses, physicians, and other care providers. It integrates the workflow within the departments and outside as well, by providing integrated information regarding patient's records. As this integrated data can be searched and gathered, revealing patterns and trends on multiple levels for various professionals involve like individual healthcare providers, clinics, public health disease tracking, and for population health management as well (www.chcf.org). Thus, EHR system provides various methods for data collection and integrates the workflow for variety of healthcare professionals involved.

Safety and Outcomes Analysis

There are many safety measures associated with EHR system we use in our military hospital. EHR system makes health professionals capable of diagnose diseases with reduced or prevention of medical errors which results in better medical care providence for ...