Question

1. Discuss the advantages of being able to document the assessment of your patient at the point of care with an electronic record rather than a centralized charting location (3)

2. Explain how point-of-care documentation of your patient assessment can be used as an opportunity for patient teaching. (3)

3. What point-of-care information can you obtain from an electronic medical record about the patient’s past and present oxygenation status that may influence immediate nursing interventions? (2)

4. How might point-of-care recording of pulse oximeter values have an advantage over recording them from a centralized monitoring station in the intensive care unit? (2)

Answer 1

ANSWERS

1. Electronic medical records (EMR ) are digital version of paper charts in clinician office, clinics, hospitals. it contain information collected by clinicians and used for diagnosis and treatments.

example fior EMR are eClinical Works, allscripts, NextGen Healthcare, Epic

basic compnents of EMR are :

• patient managment component
• clinical component
• laboratory component
• radiology information system
• billing system

advantages of electronic health records :

• provide accurate , upto date ,complete information about patient at point of care
• provides more effectively diagnose patients , reduce medical errors , and provide safe care
•   quick access to patients record for cordinated and efficient care
•   improove patient and provider interaction and communication
• enable safer , more reliable prescribings
• enhancing privacy and security of patients data
• reduces costs through decreased paper works, improoved safety,
• helps health providers to improove productivity and work life balance

2. point of care documentation is the ability for clinicians to document clinical information while interacting with and delivering care to patients.

this system assist clinicians by minimizing time spent on documentation and maximizing time for patients care.

types of information captured within these documents include patients medical history , allergic history, immunization status , past surgery , past hospitalizatiom , lab and diagnostic reports , vitals , patients demographics,

point of care documentation allows clinicians to give health education to patients also.if the patient is giving history of chronic life style diseses like diabetes, hypertension , stroke ... allow the care givers to give proper information about what to do , what precaution to take, what treatments can take, how to avoid complications , what is the importance of periodic medical checkup ,what life style changes can be practised to controll its progression, what dietary adjustments have to do... . If the patient is giving history of drug allergy in the past, we can tell pateints to take a sample of every new medication under tongue before swallowing fully, and wait for 30 minutes for looking for development of any allergic symptoms like itching , rashes, breathing dofficulty, and to get medical help as soon as possible... like these we can give health education while doing point of care documentation.

3. if a person comming emergency department with compliant of breathlessness, and pursed up lip , hyperventilation difficulty in movement..... if the patients electronic medical records are available , then it is easy for the clinician to find out most probable diagnosis , eg , if the patient have copd history and on treatment and he come with acute excacerbation , we can treat this case in the line of mangment of copd , similarly if a patint come to emergency with compliants of chest pain and breathing difficulty, sweating...medical records shows history of smoking , diabetes, bp not on medictions ,hyperlipidemia ... we can suspect acute myocardial infraction and can manage accordingly. if the patients oxygen status knows from point of care , we can do immediate intervention like supplemental oxygen , tracheal intubations, emergency tracheostomy.....

4. point of care recording of pulse oximeter values have importance for emergencty managment, because in emergency we have to act fast for good patients care, suppose if a patrient with road traffic accident is comming to emergency department with hisory of injury to chest, but patient is stable, we may think he is ok , no problem, but on pulse oximeter examination we can find out his satturation is not good ,in these cases we can give oxygen supply and can send for further investigatioin with on flow oxygen and continious saturation monitoring with portable monitoring devices like pulse oxymeter. in emergancy , before shifing the patient to icu and connecting with proper machines ,wer can know the staus of patient and what emergency managment we should do before shifting to icu through these tiny but effective machines like pulse oxymetetr as a point of care managment.