Promoting standardized nursing language using an electronic medical record system.
Paper-based medical record systems are becoming obsolete with the advent of electronic medical record (EMR) systems. With EMRs, patient data can be accessed instantly, patients can be tracked intelligently, and safeguards can help prevent medical errors. By integrating a universal nursing language, such as the Perioperative Nursing Data Set (PNDS), into EMR systems, nurses can document the nursing care they give to patients. This allows nurses to show the value of their role in the OR, promote nursing, and explain how their actions help meet National Patient Safety Goals. The transition to an EMR system for Jackson Health System, Miami, is discussed, including integration of the PNDS into the EMR system.
Doyle
Marc
M
Jackson Health System, Miami, USA.
D004282:Documentation / Q000379:methods / Q000592:standards*; D005431:Florida; D006801:Humans; D007802:Language; D016347:Medical Records Systems, Computerized / Q000592:standards* / Q000639:trends; D013527:Perioperative Nursing / Q000379:methods / Q000706:statistics & numerical data*; D018511:Systems Integration