Incorporating Standardized Nursing Language in the Electronic Medical Records

Transitioning from the conventional paper-basedmedical perioperative nursing language in the EMR,
systems to the <a rel="nofollow"perioperative nursing documentation can be
onclick="javascript:pageTracker._trackPageview('performed in a consistent and uniform manner.
outgoing/article_exit_link');" href=" MedicalNowadays, despite the high costs of some of the
Records</a>EMRs in the market, more and more hospitals in
(EMR) software offers a much improvedthe U.S and in some parts of the globe are
approach in the documentation of medicalgradually transitioning to electronic medical
records.  One feature that Electronic Medicalrecords.  One main reason for this is that the
Records offer is the incorporation of standardized<a rel="nofollow"
nursing language which will make the nurses in theonclick="javascript:pageTracker._trackPageview('
healthcare team work more efficiently in aoutgoing/article_exit_link');" href="  system
well-coordinated manner and at the same timeinterconnects all departments – pharmacy,
limit the likelihood of lawsuits secondary to clinicalancillary, laboratory, care management,
errors. Compared to the paper-based medicaladministrative, and billing sections.  With these
records, the EMR does not allow problems thatdepartments merged, smooth workflow of the
are inherent to the paper-based medical recordsentire healthcare organization is warranted
that can jeopardize both medical and nursingbecause of improved communication among
practice.healthcare providers and efficacy in work.
Electronic medical records allow coordinationElectronic medical records software also
among the members of the healthcare team,safeguards the nurses who are the primary
which means that all those who are directlycontacts of the patients from medication errors. 
involved in the care of the patient are able toMost often, nurses are having trouble deciphering
access the patient’s medical files whicheversome physicians’ handwritings.  This
department they maybe at the moment;sometimes leads to misinterpretation of drug
whereas with the traditional paper-based medicalnames and medication errors.  With the EMR
records, only one person is allowed to handle andincorporated in the care delivery system, nurses
access the patient’s file at a time.  There isare able to comprehensively monitor on the
also a greater chance of accidental misplacementcomputer all pertinent information regarding
and/or loss of some of the files in themedication prescriptions and drug administrations. 
patient’s chart with frequent flipping throughThe EMR software also comes with alerts and
thick pages and/or handling to find pertinentalarm signals that prompts the physician for any
information leading to redundant requests ofmiscalculations of drug dosages and  drug
laboratories, x-rays and prescription ofinteractions based on the patient’s present
medications.and past medical history that are keyed-in in the
It’s not only the nurses in the wards who willduring history taking. Preoperatively, nurses in the
benefit from electronic medical records but alsorecovery unit can also access the patient’s
the nurses in the Operating Room Complex.  Thetherapeutic records and be able to correlate
electronic medical records are also customized tomedications that are given preoperatively like
meet the requirements of all those involved in theprophylaxis antibiotics, intraoperatively like the
medical and surgical setting. Nurses who aretype of anesthesia given and the medications that
assigned in the perioperative care of the patientsare about to be given postoperatively.  With the
have different tasks and language documentationnursing language being standardized nurses are
that are inherent only to perioperative nursingable to document all of the nursing care and
practice.  With the incorporation of standardizedinterventions rendered to the patient accurately.