Electronic medical records are digital versions of medical charts. They contain all patients’ medical information, such as immunizations, previous consultations, allergies, past medication, diagnoses, and so forth. But the information in EMR systems cannot be shared outside the practice or clinic that created it. Nevertheless, software for EMR nursing plays an important role in patient care within the organization where it was created and maintained.
Nurses are the main caregivers after a doctor’s consultation. They offer the necessary medication, diet, prescriptions, and post-care recovery advice. Charting systems for nursing enable nurses to access the necessary details like doctors’ notes, diagnoses, and patient care recommendations. As a medical organization grows, it is bound to handle more patients, requiring an increasing number of nurses. This makes it important to implement protocols for electronic charting in nursing.
How Charting Systems for Nurses Help?
Nurses are a vital component of the healthcare industry. They observe and ensure the day-to-day wellness of patients after doctors have administered the necessary treatments. Protocols for EMR nursing streamline the overall process flow of clinical management and allows a relatively small staff to handle the care of many patients. Let’s see how nurse charting systems help –
1. Treatment Management
This is especially true for hospitals and other inpatient medical centers. Nurse charting systems allow nurses to help manage medication and dosage efficiently. A team of nurses can enter information like medication time and date, treatments, doses, and diet for patients admitted. This allows doctors to observe how patients react to the treatments administered and make adjustments accordingly.
This level of hour-by-hour observation is especially important for people suffering from chronic diseases. Any fluctuations in patient vitals can be correlated with the medications or diet, helping doctors make informed decisions. As a result, the chances of medication errors are reduced, and doctors have greater clarity of drug interactions.
Charting systems for nurses allow clinics to track patients’ progress and document the entire episode of inpatient care. This can also apply to outpatient care. Organizational protocols for EMR nursing result in all the patient’s symptoms, complaints, and other current information being updated constantly in the medical records. For people seeking outpatient care, such updated information in EMR systems helps doctors prescribe accordingly.
When the patients return for follow-ups, doctors will better understand the patient’s responses to the treatment owing to the data in the EMR. Any variations will shed light on the effectiveness of the treatment and alert doctors to adverse effects.
Custom-built nursing charting software can have templates tailored specifically according to the clinic’s needs. Moreover, automated healthcare solutions simplify the charting process with features like dictation and alerts in case of deviation of vital signs from established baselines.
3. Emergency Care
Although doctors handle emergency care, there are cases when experienced nurses must step up when the doctor isn’t available or if the clinic is short-staffed. During such times, the medical histories stored in EMR systems/EHR systems help the nurses make effective decisions faster. A centralized repository of medical information is extremely helpful for nurses to handle emergencies, at least until a doctor becomes available.
Types of Software For EMR Nursing
On-Premises Nursing Charting Systems Software
This type of EMR system is installed on the servers of the hospital, clinic, or nursing facility. The organization is responsible for all the day-to-day activities done on it, in addition to regular updates. The advantages of using on-premises software are that it can be customized per the organization’s requirement and maintains complete autonomy of the system (under regulatory compliance). Moreover, it is independent of the quality of internet connectivity as the organization’s internal network is used for accessing and sharing medical records.
However, the downside of using on-premises EMR nursing software is the initial cost of setting up. The hospital or clinic must invest in the required storage, server hardware, and IT infrastructure. Any expansion of capabilities would incur additional costs for the necessary hardware and the potential loss of valuable data in disasters like fires, earthquakes, and other outages.
Software Service Provider
This type of EMR nursing software is obtained on a subscription basis from one company but hosted on remote servers by another cloud services provider. Healthcare cloud computing solutions have increased in popularity in the last decade, leading to the mushrooming in the market for such software.
The advantage of using a cloud software provider is that the organization doesn’t need to invest in hardware or IT infrastructure. So, the initial costs are considerably lower than that of on-premises software. Additionally, the EMR systems’ data can be securely accessed from anywhere, securely over the internet. This is enormously beneficial in the case of remote patient monitoring programs at assisted living and nursing facilities for seniors.
Software As a Service (SaaS)
This is similar to the type of EMR nursing software provided by one company and hosted on a third-party server by another, as mentioned previously. But the difference is that the company that offers the software also hosts it on its servers. The software, along with the hosting services, are offered on a subscription basis. The same company manages all the responsibilities of maintaining the software, storage, processing, and backups.
The SaaS provider also handles updates to the EMR nursing platform without additional charge. This type of medical records software is rapidly growing in popularity among small and large healthcare facilities in the United States and the world over. It is less expensive, secure, complies with regulations, and offers flexibility for storage. Moreover, such software can also be used at single-physician practices and integrated with practice management solutions.
Cloud-Hosted Nursing Home EMR Systems
This is a digital platform to manage day-to-day activities at nursing homes. Such facilities offer non-emergency care, usually for seniors and others needing frequent observation but not emergency medical intervention. This software provides a dashboard that shows all the relevant information about everyday activities. It also enables the caregivers to access the required information securely from outside the facility. Subscribing and making it operational as a nursing charting system is simple and can happen within a couple of days.
Nurses are crucial in the day-to-day activities at large hospitals and smaller organizations. This includes both clinical as well as administrative roles to help make the overall patient experience better. Since EMR systems offer a central repository of patients’ information, it is logical that protocols for their usage also include the team of nurses.
As the healthcare industry adapts to the growing popularity of telehealth solutions and grapples with the growing demand for senior care, we can expect to see a shift in the role of nurses. This shift is best complemented by broadening the scope of EMR and enabling a greater involvement of nurses in primary care and non-emergency care.
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Written by Riken Shah linkedin
Riken's work motto is to help healthcare providers use technological advancements to make healthcare easily accessible to all stakeholders, from providers to patients. Under his leadership and guidance, OSP Labs has successfully developed over 600 customized software solutions for 200+ healthcare clients across continents.