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Content: Kathy Faber RN, MSN,CNL
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Use the nursing process to take advantage of EHRs’ capabilities and optimize patient care. Takeaways: If not used properly, the electronic health record (EHR) can create communication gaps. The nursing process can be applied to electronic documentation to avoid workarounds and close gaps in communication. Effective use the EHR can improve patient safety and care outcomes. Clinical documentation supports patient care, improves clinical outcomes, and enhances interprofessional communication. When you document your assessments, plans, and actions, you rely on nursing practice standards, organizational policies, meaningful use directives, and a variety of quality criteria. Electronic health records (EHRs) support that documentation with data that help you enhance patient safety, evaluate care quality, maximize efficiency, and measure staffing needs. And they serve as a standard form of documentation that can be shared by everyone on the healthcare team. However, when not used appropriately, EHRs can reduce nurses’ use of their critical-thinking skills, increase reliance on workarounds to bypass forms, and lead to errors and lost documentation.