Documentation of care has been one of the accountability of nursing professionals. Traditionally, nurses have utilized paper records for this purpose (Wood, 2005). Another function of nurses in terms of patient records is the management of patient data. By being managers of patient care, nurses refer patients to various departments for the health care team to work on patient care. Again, Wood (2005) explains that nurses do these referrals by sharing of patient paper records to those directly involved in patient care.
With the advent of EHR’s, however, these functions have been resorted to electronics with the promise of enhancing patient care and improved data storage and transfer (NIH-NCRR, 2006). Thus documentation of care has been encoded into computers and data viewing made more liberal. These have both positive and negative effects to the nursing practice. Documentation of Care EHR’s have been professed to improve documentations as they provide easier way for data encoding (NIH-NCRR, 2006).
NSW-MACPHI (2000) says that EHR aids documentation by keeping nurses up-to-date with medications, diagnostic testings, and order alerts. Documentations are also less fragmented as the EHR’s require full data documentation (NSW-MACPHI, 2000). Nonetheless, some negative effects can also be seen. Increased documentation time can be observed when technical problems occur such as slow system response, system crashes, and multiple screen problems (NIH-NCRR, 2006).
According to the NSW-MACPHI (2000), there are those that claim that EHR provides complete and accurate record that can reduce adverse events while some others say that EHR’s cannot be solely relied upon as there are many reasons that certain data maybe missing or inaccurate which can be more dangerous to patients. When human and technology meet, there is an error bound to happen and the documentation process can be a victim with the nurse legally accountable for such. Thus, there are times that instead of aiding documentation processes, EHR’s become a more tedious and fearsome work.
Sharing of Patient Data In sharing patients’ data, a system of linked electronic health records has the possibility to allow better sharing of information between health providers and consumers resulting to better health communication (NSW-MACPHI, 2000). Also, there results a reduction of possible errors in information transfer (NSW-MACPHI, 2000). With EHR’s, patients are able to gain access to their data thereby increasing their knowledge and participation in their own care (NSW-MACPHI, 2000).
Yet, on the other hand, potential risks of this liberal viewing of patient data according to the NSW-MACPHI (2000) are: a) threat to the confidentiality provided by the doctor/patient relationship; b) sensitive data could be accessible to a wider range of health providers, thereby increasing the risk of misuse or unauthorized disclosure; c) increase pressure and demands for access to the information by non-health care bodies (e. g. insurers, employers, law enforcement, some government agencies); and, d) fear that some information (e. g. about mental illness or disabilities) may result in people being treated in a discriminatory manner.
With all these benefits and risks in the documentation process and patient data sharing, EHR implementation must be properly planned and executed so it can bring about more of its positive effects and reduce its unintended negative consequences. Also, the introduction of such a technology cannot be immediately embraced by the traditional paper record-user nurses. Thus, strategies for the implementation of EHR in the nursing practice have to be employed for this positive effects and transformations to surface.