Now let's switch gears to look at how we can record.
There's several different methods
and it'll be based on facility.
So one of those is paper recording.
So there's a lot of facilities that don't do paper
recording anymore, but it is still in existence.
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.
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.
Next, another form of medical
documentation is narrative documentation.
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.
It can be very long, repetitious, and it
can be really disorganized to be honest.
Now, let's look at electronic health record.
Thank goodness for the electronic health record.
Like we talked about, this EHR
helps communicate a lot of information.
The doctors can be on a totally different
floor or even at home, and they can access this
and we can communicate together.
So this is a digital version of the patient's medical record.
And as a student, this is mostly
what you're going to be exposed to.
And again, like we talked about earlier,
it definitely improves continuity of care.
The next documentation you may be
seeing is problem-oriented medical recording.
And this database is organized by patient's health care problems.
So now let's focus on electronic health
record, or otherwise known as EHR.
This is the gold standard for documentation because
of its versatility, its accessibility, and its ability overall.
So let's discuss five different points of
why EHR is so widely used in documentation.
So number one, it summarizes the patient
care information in one central location.
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.
I think we have a better use of
our time, probably with the patients.
It also allows for fast and more streamlined communication.
It also allows for multidisciplinary access.
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.
The other thing for nursing particularly, there's
flagging, trending and screening of patient status.
So this becomes important for us in regards to
fall risk assessment and especially vaccinations.
Lastly, EHR helps to facilitate direct patient care.
So for example, the medication administration
record and barcode scanning for safety.