ppt课件-electronic health recordsand nursing- v a h s r d（电子健康recordsand护理v - h s研发）.pptVIP

Electronic health records and nursing Applications to nursing care Anne Sales, PhD RN Faculty of Nursing University of Alberta, Edmonton, Alberta Objectives Develop a common understanding of the challenges in developing an EHR optimized for inpatient nursing care Discuss the needs of inpatient nursing Situate needs within the context of VA’s EHR Describe future opportunities Overview Background comments Inpatient setting Applications of EHR in inpatient nursing care Possible future directions A couple of important notes Nurses cross all settings in health care Inpatient intensive, acute, and sub-acute care Long term care Ambulatory care Outpatient care Ambulatory surgery What nurses do in each setting can be highly variable Focus here on inpatient acute care nursing But generally, what nurses do has not been the focus of information systems Nursing care is often perceived as invisible What do nurses do? Surveillance function Delivery system for therapeutics Medications Procedures or treatments such as wound or tracheostomy care Important component of safety in delivering therapeutics Ensuring right person, right dose, right timing, etc. Risk assessment Falls, pressure ulcers, social support, other possibly preventable adverse events Care planning and intervention to minimize risk Education and advocacy Role of EHR in interacting with nursing care Documentation Includes care documentation as well as workload Prompting Force functions Decision support The acute inpatient setting Probably best understood setting in terms of nursing care and what nurses do High patient acuity From critically to seriously ill High dependency for meeting basic needs Breathing, moving, hydration, nutrition, toileting, pain control, anxiety/stress High intensity of care activities Very dynamic High levels of activity Time sensitivity Components of an EHR potentially applicable to inpatient nursing Order entry Medication delivery: Bar-coded medication administration (BCMA) Documentation Te