00:01
Now let's switch gears to look at how we can record.
00:04
There's several different methods
and it'll be based on facility.
00:08
So one of those is paper recording.
00:11
So there's a lot of facilities that don't do paper
recording anymore, but it is still in existence.
00:17
So we paper record, it is episode oriented,
and also just keep in mind with paper recording,
continuity of care can kind of be lost from each episode.
00:27
Because when we paper record, there's lots
of lots of nursing notes like we looked at earlier,
so this can be kind of hard to follow.
00:36
Next, another form of medical
documentation is narrative documentation.
00:41
So the problem with this, it's more
like a story format and you can imagine
if someone's doing something in a story format
when they document, probably not very concise.
00:51
It can be very long, repetitious, and it
can be really disorganized to be honest.
00:57
Now, let's look at electronic health record.
01:01
Thank goodness for the electronic health record.
01:04
Like we talked about, this EHR
helps communicate a lot of information.
01:08
The doctors can be on a totally different
floor or even at home, and they can access this
and we can communicate together.
01:15
So this is a digital version of the patient's medical record.
01:19
And as a student, this is mostly
what you're going to be exposed to.
01:22
And again, like we talked about earlier,
it definitely improves continuity of care.
01:28
The next documentation you may be
seeing is problem-oriented medical recording.
01:34
And this database is organized by patient's health care problems.
01:39
So now let's focus on electronic health
record, or otherwise known as EHR.
01:44
This is the gold standard for documentation because
of its versatility, its accessibility, and its ability overall.
01:52
So let's discuss five different points of
why EHR is so widely used in documentation.
01:58
So number one, it summarizes the patient
care information in one central location.
02:04
I don't know about you, but as a nurse, I
don't want to look at five different places
or six different places to find documentation.
02:11
I think we have a better use of
our time, probably with the patients.
02:15
It also allows for fast and more streamlined communication.
02:20
It also allows for multidisciplinary access.
02:24
So why that's important to us? We can
read physical therapy notes, the provider notes,
or even look at different data points
that are important in patient care.
02:35
The other thing for nursing particularly, there's
flagging, trending and screening of patient status.
02:42
So this becomes important for us in regards to
fall risk assessment and especially vaccinations.
02:49
Lastly, EHR helps to facilitate direct patient care.
02:53
So for example, the medication administration
record and barcode scanning for safety.