SamplesExploratoryThe Effect of Computers on HealthcareBuy essay
← Artificial IntelligenceIntercultural Training Models →

Free Example of The Effect of Computers on Healthcare Essay

In the timeframe of the last 20 years, a set of the documentation systems has occurred. Such a trend is mainly caused by the changes in the healthcare delivery system and advanced technologies occurrence. The new technologies have created the new expectations from the documentation.  As a response for the applied system of documentation, there is a need in the accurate and meticulous documentation in order to meet the requirements set by the existing practice. In such a manner, the possibility to minimize the incomplete or inaccurate documentation is achieved.

While referring to the fact that the total computerization has taken its place in the timeframe of the last 10-15 years, the healthcare records are also executed with a help of the PC.  The principles of documentation are common for both paper documentation and its electronic version.

Keatings, M. & Smith define the online documentation as a “technology that automates the capture of clinical care data. In the nursing realm, this can include assessment data, clinical findings, and nursing plans of care, nursing interventions (along with results), patient’s progress toward goals, critical pathways, medication administration, risk assessments, discharge planning, patient education and more” (Keatings & Smith 115).

A set of secure features is required by the electronic documentation systems in order to protect the confidentiality of the client and prevent other existing forms of the documentation entries modifying. After completing the documentation, the entries are to be locked by the program and transferred to the form of the “read only” information. There is a general requirement to the practice setting policies, namely the access to the information should be provided to the staff of the healthcare establishment only in the scopes of the specific area of practice. Only selected staff is to be provided with an access to the complete information, concerning the particular client (patient). In order to guarantee the passwords, they are to be changed at the specific time intervals. The level of access to the information is defined in accordance to the username.

 It is important to emphasize that the doctors and nurses should be allowed to access the e-health system only using their personal username and password. This is done in order to ensure that a particular nurse or doctor has accessed the system at the particular time and place.

In case, if there are two forms of documentation in the healthcare establishment (paper and electronic), there is a need of the continuity of care maintenance. Therefore, there is a general requirement to identify the paper-basedhealthcare records with a help of the e-health system. In case, if the paper healthcare record is used, when there are some technical problems with the electronic system, the reader should be redirected by the paper healthcare record.

 The care provider is required to put a signature in the e-health record. It is important to put an emphasis on the fact that the electronic signatures are valid. The core purpose of using them is demonstration of the accountability. These signatures are technically accessible only to a person, which is identified by asignature.

In case if the incorrect entries take place, they must be corrected. The remark of the corrector and time of correction and place are obligatory.

Awareness of the healthcare establishment personnel in the ways of e-documentation correction is also obligatory. It is important to put an emphasis on the fact that any type of information as well as other forms of documentation, which have been used for the healthcare record, cannot be deleted.

The nurses and doctors are required to refer to their employer’s policy if the additions or changes are made to the e-health record.

All the entries to the healthcare record are to be voluntary. In the case, if the entry is late, it should be marked correspondingly. All the corrections, alterations or deletions of the e-health records are to be documented carefully. By the way, the date is to be put, including the hour and the signature of a nurse or a doctor; the additions or changes to the file are to be put as well.

The last issue to be discussed in the scopes of this paper is the methods of documentation for the healthcare system.

There is a set of effective documentation techniques, which are directed for the appropriate solutions in a particular healthcare organization.

The narrative documentation technique is considered a traditional method for the provided nursing care recording. Documentation is accomplished in a form of story. There is no organized framework, and the data is recorded in a form of the progress notes. The reader is often required to sort the information.

The Problem-Orientated Medical Record (POMR) implies a single list of client problems, which is made by the members of the healthcare team.  The basis for the POMR method is formed by the nursing process.

In the case of the POMR, the chronological problem number is not repeated in the timeframes of one hospitalization. After a treatment is accomplished and the problem is resolved, the modification of the list is made by checking off the area next to the listing or by signing a space. Furthermore, the date of the problem resolution is noted next to the signature.

While referring to the SOAP/IER method, it should be noticed that it is the problem-orientated documentation method. It is structured in such a manner that the notes of the narrative progress are written by the members of the healthcare team. The SOAPIE, SOAP or SOAPIER format is applied in this case. Meiner (1999) gives the following interpretations of the abbreviation: subjective client’s observations; objective care provider’s observations and tests; assessment of the care provider’s understanding; plans, goals, action, advice; intervention was identified and changed to meet the client’s needs; evaluation of care outcomes; revision when changes of the original problem come from the revised interventions, outcomes of care or time lines are used to denote the changes.

 The PIE (problem, intervention, evaluation) method implies that there are numbers and labels (given in accordance with the client’s problems) for all the notes.  The resolved problems are eliminated from the daily documentation after the review is done by a doctor or a nurse. The daily documentation is done only for the continuing problems (Potter et al. n.pag.).

Such a documentation technique as Focus Charting (DAR) includes subjective and objective data, actions, and the clients’ responses.  The core emphasis of this documentation technique is made on avoiding the problems with documents.

To conclude, it is important to pay additional attention to the fact that computerization of the documentation system has improved the quality of documentation and minimized the quantity of mistakes.

Code: Sample20

Related essays

  1. Intercultural Training Models
  2. Emerging Powers Growing Concerns
  3. Artificial Intelligence
  4. The Wind Power
Testimonials
View all
call-back-button
Live chat