Annotated Bibliography on Electronic Health Records Nursing Informatics Stefanie Kelly Donna Jean Bailey November 2, 2014 Introduction Quality and safe delivery of care has been a focus in the development and utilization of an electronic health record. Within the past fifty years, advancements in technology have changed the concept and management of the electronic health record. The relevance to nursing informatics is how this information is managed to ensure clinical and practice standards are met with current changes in technology as well as ensure continuity of care. Improved documentation, safer ordering and medication administration are a few examples of how electronic health records are important to nurses. The advancement …show more content…
Increasingly complex systems have caused concerns with safety and functionality and usability of the systems. The authors, specializing in Informatics and Health and Science, and with the support from the National coordinator of Health Information and the Patient Safety action and Surveillance organization, have developed SAFER guidelines for consideration. The guidelines are a proactive approach for organizations to assess safety risk and to identify and resolve concerns. First, they identified system vulnerability and risk for error, which will enable users to implement improvement methods. The second was the identification of 6 safety principles within 3 phases of the implementation of an EHR. Key stakeholders use a multidisciplinary approach with the SAFER guidelines. Proactively improving systems and driving safer, improved outcomes. The safety implications are what make the scope of nursing informatics relevant, by being part of a multidisciplinary group to continually assess nursing clinical guidelines and safe …show more content…
Nursing and Informatics are positioned to be part of this initiative of achieving certification with their organizations. It has been difficult for smaller practices to achieve without established electronic health records; however the push to align with the Medicaid drives the incorporation of records in offices. These measures are intertwined with the oncology quality measures. Tracking information has now become easier with the electronic chart. Developments with palliative care, oral chemotherapy, survivorship and fertility preservation, require improvements in order to capture and track the data effectively. Nursing personnel are often part of a collaborative team to pull the data for reporting, this is another example how nursing needs to stay abreast of the technology and