Fundamentals of Nursing Q 43
Patient Z asks Nurse Toni why an electronic health record (EHR) system is being used. Which response by the nurse indicates an understanding of the rationale for an EHR system?
A. It includes organizational reports of unusual occurrences that are not part of the client's record.
B. This type of system consists of combined documentation and daily care plans.
C. It improves interdisciplinary collaboration that improves efficiency in procedures.
D. This type of system tracks medication administration and usage over 24 hours.
Correct Answer: C. It improves interdisciplinary collaboration that improves efficiency in procedures.
The EHR has several benefits for users, including improving interdisciplinary collaboration and making procedures more accurate and efficient. An Electronic Health Record (EHR) is an electronic version of a patient’s medical history, that is maintained by the provider over time, and may include all of the key administrative clinical data relevant to that persons care under a particular provider, including demographics, progress notes, problems, medications, vital signs, past medical history, immunizations, laboratory data, and radiology reports The EHR automates access to information and has the potential to streamline the clinician’s workflow. The EHR also has the ability to support other care-related activities directly or indirectly through various interfaces, including evidence-based decision support, quality management, and outcomes reporting.
Option A: An occurrence report is an organizational record of an unusual occurrence or accident that is not a part of the client’s record. The purpose of the incident report is to document the exact details of the occurrence while they are fresh in the minds of those who witnessed the event. This information may be useful in the future when dealing with liability issues stemming from the incident.
Option B: Integrated plans of care (IPOC) are a combined charting and care plan format. It is care that is planned with people who work together to understand the service user and their carer(s), puts them in control, and coordinates and delivers services to achieve the best outcomes
Option D: A medication administration record (MAR) is used to document medications administered and their usage. A Medication Administration Record (MAR, or eMAR for electronic versions), commonly referred to as a drug chart, is the report that serves as a legal record of the drugs administered to a patient at a facility by a healthcare professional. The MAR is a part of a patient’s permanent record on their medical chart.