In most circumstances, I find that pen and paper is the quickest and easiest way to take a note. The materials needed are almost always at hand, and never need to be plugged in or connected to internet. Before practicing in a real clinical setting, I thought that pen and paper would be the best way to record patient information. However, despite the many perks of pen and paper, I have discovered that there are cons to this method, especially when it comes to professional, confidential health records and documentation. For instance, papers can be seen by anyone, even if they are hole-punched in a binder. Also, handwriting varies from person to person, and errors made with pen are difficult to correct. This may lead to misinterpretation of healthcare information, which may cause harm to patients.
This, among other reasons, is why I prefer electronic health records over paper charting. I have used both paper and electronic charting in clinical settings, and have learned about many perks of electronic health records in lectures and presentations, such as health information exchange (HIE). HIE is the transfer of health information and records among medical facilities, providers, and patients. The history of HIE has changed immensely over time. It started with mailing information by post from facility to facility. Later, information could be given over the phone or via fax machine. Today, we are fortunate to have programs such as HealthInfoNet, which allows facilities and providers to access all patient information, with the patient’s consent.
After learning what I have about electronic health records up to this point, I can provide better care for my patients when I enter the nursing practice. By using the computer to record patient information, I will be able to easily identify trends in my patients’ vital signs and lab values. I can also immediately look up certain medications that I do not know off the top of my head, if a patient has a question about it. In addition, if a patient is admitted with minimal information to relay, I will be able to look them up on programs such as HealthInfoNet in order to gain a better understanding of the patient’s history and current medical condition. There are so many more benefits to electronic health documentation, and I am excited to have all these possibilities available to me once I enter the nursing practice.
