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Methods of Documentation VII: EMR

Methods of Documentation VII: EMR

Electronic Medical Records (EMRs) primarily center around electronically documenting patients' health information within a single healthcare organization or practice. They contain essential clinical data related to a patient's medical history, diagnoses, medications, treatment plans, lab results, and other pertinent information relevant to the specific encounter or episode of care. EMRs are designed to streamline documentation and workflow processes within individual healthcare settings,...

Purpose of Health Records I

Purpose of Health Records I

The vital purpose of health records is to provide a complete and accurate account of a patient's medical history, including communication, diagnostic and therapeutic orders, care planning, research, and quality review.
Here's a breakdown of how health records serve these purposes:

Types of Records II: Educational and Administrative Records

Types of Records II: Educational and Administrative Records

Maintaining nurses' educational and administrative records in healthcare settings, including hospitals and nursing schools, is paramount. Here's a breakdown of the types of academic records mentioned:

Purpose of Health Records II

Purpose of Health Records II

Health records serve various essential purposes in the healthcare system. Here are some key purposes:

Data Reporting and Recording

Data Reporting and Recording

Reporting and recording are crucial in data documentation. The timely, thorough, and accurate documentation of facts is essential when recording patient data. Failure to record findings during an assessment or interpretation of a problem will result in loss of information and make the patient document unreliable. The reader is left with general impressions if the information is not specific. A recording is documenting data of the individual's health information in a traceable, secure, and...

Archival Research

Archival Research

Some researchers gain access to large amounts of data without interacting with a single research participant. Instead, they use existing records to answer various research questions. This type of research approach is known as archival research. Archival research relies on looking at past records or data sets to look for interesting patterns or relationships. For example, a researcher might access the academic records of all individuals who enrolled in college within the past ten years and...

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Related Experiment Video

Updated: May 27, 2026

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

Published on: September 18, 2018

Assessing the value of electronic records.

Keith Edwards¹, Denise Chiweda, Appiah Oyinka

¹Open University.

Nursing Times

|December 3, 2011

Summary

Mental health nurses find electronic records impact patient care time, citing training needs and workflow issues. Improving computer access and dedicated spaces can enhance patient involvement in electronic care planning.

Area of Science:

Nursing Informatics
Mental Health Services
Healthcare Technology

Background:

Introduction of electronic health records (EHRs) has raised concerns among nurses regarding data input time.
Nurses report potential negative impacts on direct patient care due to increased computer use.

Purpose of the Study:

To explore mental health nurses' perspectives on computer use during patient care planning.
To investigate the role of electronic records in enhancing service user involvement and care planning within mental health settings.

Main Methods:

A mixed-methods approach combining a literature review and a descriptive survey.
Questionnaires were distributed across 10 mental health wards.

Main Results:

Related Experiment Videos

Last Updated: May 27, 2026

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

'Boden Food Plate': Novel Interactive Web-based Method for the Assessment of Dietary Intake

Published on: September 18, 2018

Nurses expressed concerns about electronic records affecting patient interaction and identified a need for specific training on electronic care plans.
Issues included duplicated work (paper and electronic), insufficient computer availability, and lack of private spaces for joint care planning.
A key benefit noted was improved readability of patient information.

Conclusions:

Addressing staff training, availability of private interview rooms, and staff attitudes is crucial for effective EHR implementation.
Evaluation of electronic care plans should focus on patient care quality, nurse-patient interaction, and collaborative partnership working.