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Hello, I need Tow peer response , My professor is very strict in grading so plea
Hello, I need Tow peer response , My professor is very strict in grading so please be as specific as possible in answering the question. I will be generous with you!
This is My post: to help you with the peer responses: Non-electronic nursing intervention can significantly impact patient outcomes, leading to gaps in care, delayed treatments, and compromised safety. Nurses may prioritize urgent patient needs over documentation, such as providing epinephrine or other medications in emergency departments, rather than documenting every procedure in the EHR. Nurses in complex cases with multiple treatments may struggle to record all actions, such as in intensive care units where immediate resuscitation is crucial for patient survival. Technology issues or failure of Electronic Health Record systems can also hinder recording, leading to manual documentation or directing attention to patients instead of electronic documentation. Nurses must ensure timely and accurate interventions to ensure patient survival. In my clinical practice at my Saudi university, I observed nurses not documenting nursing steps manually due to emergencies. This was particularly problematic during code blue events, where immediate life-saving operations were crucial. To mitigate this, healthcare organizations can implement post-event documentation protocols, requiring immediate documentation after resolving the emergency. The assistance of scribes or documentation assistants during high pressure ensures precision and timeliness, ensuring excellent patient care quality. Implementing a robust Electronic Health Record (EHR) system with built-in resilience and redundancy reduces the risk of system breakdown or technological limitations (Shaikh et al. 2022).
Healthcare institutions can enhance nursing recognition and visibility by providing continuous training and education, emphasizing electronic documentation and standardized terminology, and enhancing interdisciplinary collaboration between nursing informatics, IT professionals, and bedside nurses. Performance metrics can evaluate the quality and efficiency of documentation and the impact of nursing interventions on patients using EHRs. Nurses can improve documentation practices and patient care delivery through standardized processes, inter-professional collaboration, mobile technology, universal adoption of protocols, and integration of clinical decision support tools into EHRs. Continuous participation in quality improvement initiatives can identify flaws in the documentation process and replace them with a coordinated workflow solution, ultimately improving patient care. References
Lodhi, M. K. (2017). Data Mining of High Dimensional Sparse Dataset: A Case Study of Nursing Electronic Health Records (Doctoral dissertation, University of Illinois at Chicago).
Rossi, L., Butler, S., Coakley, A., & Flanagan, J. (2023). Nursing knowledge captured in electronic health records. International Journal of Nursing Knowledge, 34(1), 72-84.
Shaikh, M., Vayani, A. H., Akram, S., & Qamar, N. (2022). Open-source electronic health record systems: A systematic review of most recent advances. Health Informatics Journal, 28(2), 14604582221099828.
1st peer post :Standardized terminology emerges as a cornerstone for effective healthcare delivery in today’s landscape at Electronic Health Records (EHRs) and seamless data exchange. Nurse informatics, working hand in glove with chief nursing officers, push their organizations to achieve meaningful use and standardized terminology, reduce documentation burdens, improve processes, and use EHR data to improve efficiency and patient care (Moy et al., 2021). The documentation of nursing contributions within EHRs is a testament to the profession’s impact on patient care. However, missing the documentation of some nursing interventions might prevent positive patient outcomes. Care at the bedside, which might need to be clearly defined or clean-cut, could be lost within the recorded data or missed potential critical interventions.
Further, opportunities to spread positive outcomes across patients might only be noticed if there is evidence of nursing’s contributions to a patient’s positive outcome. Efforts are needed to ensure that nursing’s contributions to patient outcomes are fully seen. One way to make nursing visible is to standardize EHR documentation protocols and implement them in the EHR systems (De Groot et al., 2022). Another way is to foster a culture of recognition in the health system, where nursing contributions would be documented and lauded. Finally, proposing policies for the recognition of the contributions of nurses would contribute to their visibility within the health system.
Streamlining processes and reducing documentation burdens are paramount for nursing professionals. Embracing best practices such as using templates for standard procedures, voice-to-text technology, and real-time documentation tools all speed up workflows and decrease documentation fatigue. Interoperability between EHR systems enables EHRs to communicate with each other so that the care provider can access the most up-to-date information to make informed decisions (De Groot et al., 2022). These practices help the nurse be as efficient as possible, and by increasing efficiency, we also increase patient outcomes, reminding all of us of the importance of nursing in healthcare. These efforts elevate the profession and underscore its indispensable role in promoting patient well-being and advancing healthcare outcomes.
References
De Groot, K., De Veer, A. J., Munster, A. M., Francke, A. L., & Paans, W. (2022). Nursing documentation and its relationship with perceived nursing workload: a mixed-methods study among community nurses. BMC nursing, 21(1), 34. https://doi.org/10.1186/s12912-022-00811-7
Moy, A. J., Schwartz, J. M., Chen, R., Sadri, S., Lucas, E., Cato, K. D., & Rossetti, S. C. (2021). Measurement of clinical documentation burden among physicians and nurses using electronic health records: a scoping review. Journal of the American Medical Informatics Association, 28(5), 998-1008.
2nd peer post: The EHR in a hospital may be one of the most valuable tools a nurse can use. With easy communication and easy documentation, the EHR helps to prevent most nursing errors and confidentiality violations. However, even with the documentation improvement, there are still missteps and room for improvement. One way that the EHR could be improved is by notifying anyone logging into the chart of new entries. If there has been a new entry in the chart made since the nurse last logged in when the nurse logs in again the EHR would pop up with a little notification which when clicked on would take the nurse to the new entry made in the chart. This would help keep the nurse up to date on what is happening with their patient as well as prevent double charting the same thing. This would help to prevent certain problems when it comes to charting but this solution would not be very helpful when a nurse simply does not chart. One problem seen repeatedly in the hospital is nurses giving medicine and not charting the medication. This could be for several reasons but the reason doesn’t matter. Due to a nurse not charting a medication administration a different nurse could see that a medication is overdue and give the medication again causing adverse effects. Sewell, J. P. (2016). Informatics and nursing: Opportunities and challenges (6th ed.). Wolters Kluwer Health/Lippincott William & Wilkin.
C riteria
Excellent 2 points
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1 point
Needs Improvement
0.5 points
Unacceptable 0 points
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