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Implementing an electronic medical record
Lloyd N Friedman1, Neil A Halpern, James C Fackler
1Pulmonary and Critical Care Section, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA. lloyd.friedman@milfordhospital.org
Abstract:
We consider the practical aspects of justifying, planning, implementing, and budgeting for an electronic medical record. Examples include the decision about integrating versus replacing old systems, the timing of implementation for each clinical area, preparation for installing computerized order entry, a discussion about how to implement physician progress notes, and a discussion about how electronic nursing systems interact with the EMR. Integration of other systems such as PACS and EKGs are discussed. Wireless integration and telemedicine also are addressed, as well as backup, redundant systems and budgeting. The reader will gain a full understanding of the scope of the problems involved in implementing an EMR, and will have a step-by-step description of how to approach the task.
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Introduction to Documentation and Reporting
Nursing documentation records essential information and details regarding a patient's care and treatment in written or electronic form. It is a critical aspect of nursing practice that involves documenting assessments, interventions, outcomes, and other relevant details about a patient's health status.
Documentation maps the patient's health journey by creating a comprehensive and precise...
