NCLEX-PN

●​ Electronic health record : Electronic medical records are an important part of client care. Automated orders can be placed quickly and easily instead of waiting for requisition forms to be filled out and faxed or physical forms to be delivered. Instantaneous information can reduce many potential errors as well as provide all necessary information. ●​ Instantaneous access to information : Instantaneous access to healthcare information can include a facility’s specific policies and procedures, current and valid information such as standards of care, ethical codes, and any other materials necessary for providing optimal care. This gives healthcare providers the ability to quickly access the important information that they need to provide the best client care. ●​ Data analysis : Performance improvement data and risk management data obtained from the electronic health record can be used to identify patterns and trends related to client care. This information can provide preventive care and also inform healthcare professionals on what areas of care need to be improved in order to provide the best client care. Data analysis can also be used to monitor client outcomes and medication compliance. Receiving-Processing Physician Orders Nurses are responsible for receiving and processing healthcare provider orders, whether in handwritten or electronic form. Many healthcare facilities have adopted automated orders for client care procedures and interventions and have shifted to electronic medical records. All orders must be followed up on by the nurse, such as orders the client questions, orders that seem inappropriate for the client, or orders that are incomplete and illegible. Telephonic and verbal orders are strongly discouraged. They can lead to serious adverse events. When it is necessary to call a provider to obtain an order, the nurse must fully document the order and the circumstances that necessitated the telephonic order. The nurse will then read the order back to the ordering physician to verify its correctness. Some facilities also require that two nurses hear and confirm the order. Be sure to follow organizational policy regarding telephonic and verbal orders. Computer Provider Order Entry (CPOE) is strongly encouraged to maintain client safety.

Documenting & Accessing Client Records The HIPAA Security Rule mandates administrative, physical, and technical safeguards of all forms of client information, including electronic health information. All client-related events and activities associated with client care should be electronically documented accurately, completely, and on time to ensure accurate and timely communication of client-related data. The HIPAA Privacy Rule legally limits access to medical records and information to only those who have a NEED to know during their provision of direct and indirect care to the client.

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