护理高级实践杂志

Analysis of Communication in the Electronic Medical Record: Communication of the Patient Story across the Continuum of Care

Abstract

Kaying Vang

The electronic health record (EHR) and problem list are tools used to communicate the patient’s medical story. The increase adoption of the EHR has been recognized to
improve the quality and efficiency of patient care. However, emerging reports of unrecognized implications have been found to be associated with EHR implementation and
its functionality. These implications have been found to affect the quality, safety, and efficiency of patient care. The primary purpose of this project was to retrospectively
assess the electronically written communication by following the EHR problem list as the patient progresses through each level of care during an inpatient stay starting in the
Intensive care unit (ICU). The secondary purpose of the project was to identify potential EHR tools that may improve the utilization and maintenance of the problem list. The
electronic problem list functions as the communication tool that tells the patient story, therefore it is essential that the story it tells is accurate. The findings from this study
indicated that the utilization and maintenance of the problem list in which it is accurate and complete may result in care that is of quality, safe and efficient.