Review of the literature have electronic medical records

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QUESTION

1.
week 5
COLLAPSE
In your opinion and review of the literature have electronic medical records facilitated documentation or hindered effective documentation that will legally stand the test of time?
Electronic medical records (EMR) have enhanced the effectiveness of documentation in hospitals. Some of the major benefits EMRs have helped with are fewer errors compared to paper records. Having accurate records reduces the risk of treatment errors. Additionally, EMRs have made it easier to track patient treatment progress (Guido, 2014). Therefore, EMRs have facilitated documentation, and the only hindrance that they may have is that they have ethical implications, such as the risk of losing patient data from hacking. However, EMRs will legally stand the test of time because all healthcare systems will shift to electronic data as the main form of storing patient information.
What liability does a discharge nurse have in providing appropriate and effective discharge instructions to prevent injury and/or readmission?
Discharge instructions can be a source of legal liability for a nurse. The nurse can reduce the risk by providing clear discharge instructions that a patient must sign. Ensure the patient fully understands the discharge instructions and that they have been attached to the patient records to prove that the instructions were provided and that the patient received them.
For example, what is nursing’s role when confronted with a Medicare/Medicaid/Insurance driven discharge when the nurse is questioning the discharge?
The nurse’s role when questioning an insurance discharge is to examine the status of the patient and educate them of the impending danger they face if they are to leave. Therefore, the main role of the nurse is to educate the patient on what they need to do once out of the hospital to reduce the risk of harm.
When the nurse is confronted with cultural/religious beliefs and practices that are contrary to EBP, what options does the nurse have and which should he/she take?
The nurse must respect all cultures by practicing the nursing principles and applying the code of ethics. Moreover, they must educate the patient of the benefits of the treatment procedure and the risks attached to processes not recommended by EBP. The nurse must look for safer alternatives such as holistic practices.
References
Guido, G.W. (2014). Legal and ethical issues in nursing (6th ed.). Upper Saddle River, NJ: Pearson Education.

2.
Week 5 Discussion Post
COLLAPSE
EMR is pretty much standard most places I have been to nowadays so I think that there are a lot of benefits such as better transition of care as well as charting can be done easily and quickly for a lot of things.  You can sync them to monitors and they can pull vital signs over as quickly as every minute if you wanted to without having to be in the room and be able to monitor multiple patients at once.  One of the biggest concerns I can see in my area is that failure to use it regularly on patients makes it appear that there are gaps in care and data particularly when things such as vitals are not being recorded such as when patients remove their monitor or blood pressure cuff and it goes unnoticed (Guido, 2010).
I often discharge many patients daily and I am very thorough and careful in providing education to my patients.  One of the biggest educational factors that I emphasize is when to return or call 911.  Releasing a patient can always have risks as their condition can change or worsen and I let them know that and when to return to prevent any adverse effects.  I also emphasize the importance of follow up appointments since many people discharged are cleared of any emergency situations but may have chronic issues that may need to be tested further by their PCP or a specialist.
My beliefs in everything have been towards anyone’s personal freedoms.  This is still what I believe with cultural and ethical conflicts that may arise.  I can present the evidence to the patient and what benefits and risks there are for choosing or not choosing to go with or against the medical advice from the EBP.  It will ultimately be up to them to make their decision based on the evidence presented to them versus their personal beliefs.  It may be hard to see them make decisions but autonomy is important and I believe strongly in that.

Guido, G. W. (2010). Legal and ethical issues in nursing (5th Ed.). Pearson Education Inc.

3.
Week 5
COLLAPSE
There are many benefits to an electronic medical record, benefits that far outweigh any hindrances. These benefits all facilitate accurate, detailed documentation and quality patient care.
• All documentation is legible, leaving little room for misinterpretation or incorrect order transcription.
• All documentation is quickly and easily accessible to all disciplines involved in the patient’s care.
• There is greater patient privacy, because only those with proper credentials can access certain patient information.
• There is greater coordination of care amongst different specialties, as each discipline can see any changes made by others to the plan of care (referrals, medication changes, etc.).
• Medication administration and prescribing is safer. Physicians are alerted to potential interactions and patient allergies when using the EMAR. The use of barcode scanning and the EMAR in nursing ensures proper medication dosages are being given, and are recorded at the actual time of administration so there are no discrepancies. There are less medication errors, as scanning an incorrect medication will alert the nurse to a problem. There are additional safeguards to ensure proper checks – for example, it is impossible to administer insulin without a second nurse logging into the EMAR to cosign.
Legally, the electronic medical record serves as detailed record of care provided. This could work in the nurse-defendant’s favor – or not. Electronic records are more complete and accurate, especially concerning drugs administered. If an entry is changed by anyone, there are ways to track the date/time of those changes and who made them. So it is more difficult to cover up a missed medication administration, or an incorrect medication administration due to the technological timestamp. This could defend the nurse in terms of accusations that a medication was missed (if there is proof it was administered), or work in the plaintiff’s favor if there is no documentation of the administration.
Court decisions continue to address the responsibility of the nurse to provide proper patient teaching. Effective teaching upon discharge can help to prevent injury and/or readmission; the nurse is liable if sufficient teaching is not done, and complications ensue. Nurses are expected to assess the patient’s educational needs, complete patient teaching, and then determine how well the patient understood. The standard is not met until the nurse feels the teaching has been understood.
Nurses have a duty to protect patients: against inappropriate orders, incorrect interventions, and premature discharges. If a nurse feels the patient is not stable to discharge, he/she should speak with the attending physician and the healthcare team. If there is no progress, then the nurse would inform their supervisor and upper management. If an early discharge is still imminent, the nurse has to provide (as always) thorough, clear patient education – tailored to the patient’s learning needs.
When cultural/religious beliefs do not coincide with EBP, the nurse must respect the patient’s beliefs and exercise cultural competence. If the patient is refusing care based on these beliefs, the nurse must honor this right of refusal (unless this right is denied by law). The nurse could encourage the patient to incorporate religious practices in conjunction with EBP to address a health issue.  Once again, education is key! And the nurse has a responsibility to provide thorough education to the patient, in a culturally-sensitive manner.  The nurse’s teaching may help the patient realize that the EBP is a good option, and why it is a good option.

Ginny Wacker Guido. (2014). Legal and ethical issues in nursing. Pearson.

4.
Week 5 DB
COLLAPSE
In your opinion and review of the literature have electronic medical records facilitated documentation or hindered effective documentation that will legally stand the test of time.
Electronic medical records facilitate documentation and helps nurses keep accurate and concise records that will legally stand the test of time.  However, it depends on how well the nurse documents every observation, follow-ups with patient responses, reads other nurses’ notes before giving care, makes a chart entry after an event even if its late, and uses clear and objective language.  A nurse must also avoid charting for other nurses, correct charting errors, chart patient’s refusal, chart patient education, and write full name after every entry.  The EMR is helpful in assisting the nurse with documentation and “allows for accuracy at all stages of the nursing process” (Guido, p. 197-211, 2010).
What liability does a discharge nurse have in providing appropriate and effective discharge instructions to prevent injury and/or readmission?
To prevent legal liability, a nurse must provide: clear discharge instructions that is written and verbally explained, referrals, discharge location, ways to facilitate recovery, medication information, necessary equipment/supplies, resources for coping and costs, and phone numbers to reach out to.  Also, a nurse must include as many family members in the discharge instructions to help facilitate recovery if the patient may not be able to himself.  Always offer your assistance with necessary services that the patient is instructed to follow (Discharge planning, 2019).
What is the role of Medicare/Medicaid/Insurance reimbursement guidelines on questionable discharge?  What is nursing’s role when confronted with a Medicare/Medicaid/Insurance driven discharge when the nurse is questioning the discharge?
I did not quite understand how insurance could influence discharge, so I looked up what Medicare reimbursement means and I found that Medicare uses a prospective payment system which is a “method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount” (Prospective payment, 2021).  Based on this, I assume that insurance pays for a certain amount of hospitalization days and from then on it is up the patient to pay out-of-pocket.  In a way, this may force a patient to be discharged to avoid paying hospital prices if insurance doesn’t pay for it.  Nurses have an ethical obligation to make sure the patient is being discharged safely.  Therefore, the only thing a nurse could do is inform the patient of the risks, “work with case management to create a post-discharge contingency plan”, and/or “contact nursing homes on behalf of clinicians if placement is especially difficult” (Derse & Solverson, 2016).
How would you explain the prevalence of nursing medication errors?  What safeguards have you developed in your own practice to prevent medication errors?  What quality improvement measures has your system taken to prevent medication errors?
Usually there are pop-up windows that make sure you have the right dose and you have to manually enter vital sign before giving a medication.  Also, look-alike, sound-alike medications have capitalizations to distinguish from each other.
When the nurse is confronted with cultural/religious beliefs and practices that are contrary to EBP, what options does the nurse have and which should he/she take?
A good example of this is when a patient believes in complementary and alternative medicines for cultural beliefs and that can interact with prescription medications.  What a nurse should do in this case is educate the patient on what the interactions may be, the risks involved, and why prescribed (OTC) medications may be more effective.  Most importantly, be respectful of their culture.

Derse, A., & Solverson, S. (2016, May 1). When is hospital discharge unsafe? Relias Media – Continuing Medical Education Publishing. Retrieved February 15, 2022, from https://www.reliasmedia.com/articles/137775-is-hospital-discharge-unsafe-ethical-response-is-needed
Discharge planning. Center for Medicare Advocacy. (2019, September 24). Retrieved February 15, 2022, from https://medicareadvocacy.org/medicare-info/discharge-planning/
Guido, G. W. (2010). Legal and ethical issues in nursing (5th ed.). Pearson Education, Inc.
Prospective payment systems. CMS.gov. (2021, December 10). Retrieved February 15, 2022, from https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ProspMedicareFeeSvcPmtGen

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