Academic Writing Sample:

This is a summary of the article “Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings” by Lavin, Harper, and Barr. It was published in The Online Journal of Issues in Nursing in May 2015.

Information technology is transforming the healthcare industry, as it allows for instant, remote communication and efficient record-keeping which streamlines the access to information. However, the application of new technology to nursing practice is still in its early stages. There are many issues to be resolved and areas for improvement. One problem that is a roadblock to improvement is that not all nurses are familiar with the technical language. As the article states, “Nurses were challenged to articulate their concerns due to the fact that there was no available taxonomy to describe EHR-related difficulties” (Lavin, et al, 2015). The article’s goal is to address some of the common concerns related to using EHR in caregiving.

One focus of the article was the necessity for standardization of evidence-based care processes. For example when educating the patient the nurse may choose to use their own material, instead of the EHR-generated patient education materials. Use of non-standard materials will make studies and comparisons meaningless, since the same information is not being relayed from provider to patient, even if the same information technology is being used. RNs may argue that their own material is more up to date than the computer generated material. This can be a valid point, so it then becomes important for nurses to become more involved in the selection and updating of computer-generated material. There also needs to be development on the technology side to make sure that this happens and that nurses’ involvement in this process is not hindered by their reluctance to use the technology.

Another major issue with EHR was the ability of nurses to prioritize diagnoses and to make the nursing process transparent within the documentation. “The American Health Information Management Association indicates the electronic health record should allow providers to manually order and sort the problem list… nurses need the ability to manually order or sort by priority the diagnoses that drive their interventions” (Lavin, et al, 2015). The ability to manually organize the information will contribute to a clearer and more transparent presentation of the records. As the article states, “While providers using the EHR have access to information inserted by interdisciplinary team members, access to this information is not always intuitive, nor is its presentation always clear” (Lavin, et al, 2015). This is another area for improvement on the technology side.

Overall I feel this study addresses many issues that need immediate attention for the improvement of EHR. If the roadblocks mentioned in the article can be overcome, we would be closer to gaining the full benefit from the technology.

Reference:

Lavin, M., Harper, E., Barr, N. (2015) Health Information Technology, Patient Safety, and Professional Nursing Care Documentation in Acute Care Settings. OJIN: The Online Journal of Issues in Nursing, 20 (2).