Electronic Medical Records & Charting

Derek and I are here, to talk a little bit about electronic charting and documentation here in the US. And we recognize that it can be a little different from what you guys may be currently doing.

And so we'll just talk a little bit more about the practices that is normal here in the US.

Awesome.

That's right, Ashten. So here in the US, we use electronic medical records, but you'll probably more often than not hear them called EMRs for short.

All health care professionals utilize these to document patient care, amongst other things. Everything we will discuss here is a general layout  of how electronic charting systems work. There are many different systems available to us, but a few of the popular ones are gonna be Epic, Cerner, Meditech, and PointClickCare.

Yep. Absolutely.

And so, you know, the systems beat there are quite a few, obviously. Those are just, like, the top four probably.

But there are also like, within those systems, they can be so specified to the facility, but also even the units. So let's say, for example, you know, the emergency department. Right? Their priorities are a little different than what maybe a med surge unit would be and even a labor and delivery. So each unit kinda has its own format or layout within that system.

And so, some are also more updated than others and user-friendly.

But, overall, the goal for the EMRs is to meet the needs of the units and the facilities.

Yeah. And when starting at a new facility, you will receive EMR training during the orientation process.

In general, typically, there is some classroom training that usually lasts between kinda four to eight hours just depending on whether you gain your specialty and the facility.

And if there are updates to the system or maybe some changes occur within the system, you'll also receive training for that. But then you'll also receive kind of the more EMR unit-specific, training while on orientation. So once you kinda hit the floor with your preceptor, you'll be getting you'll be able to kinda get the hands on with that a little bit better.

Yeah. Absolutely. Absolutely. And, you know, no matter where you like, no matter how long you've been in nursing, and no matter where you work, you will always get that training.

So say you start off at one facility, then end up at a different facility along your journey, you will always get that training just because of how specified and how specific they can be to what that particular, you know, hospital may need. So, you will always get that. And so, you know, they there are different systems, but the best practices in using EMRs are relatively the same. So one being it's standardized, you know, documentation.

So the formats the layouts really improve consistency between patients. So each patient has a chart within that EMR system, and each patient has the same, like, flow sheets is which we call them. And so there's an example of a flow sheet, that we'll throw up, here in a minute.

But, basically, this allows that information to auto flow super easily into even other flow sheets in the system, other views that other departments have, and even the notes that you can create or the doctor creates within that system.

And so here's a flow sheet, an example of a head-to-toe assessment. Right? And so as you can see on the screen, you have, some and this is just a little bit of it, but it just some parts of what a flow sheet could look like. And so, just to give you guys some background knowledge there.

And yeah. So it's just it's it's just really amazing on how the how far the EMR systems have even come.

Yeah. And that is a great point, Ashten. They're, like, kind of a key point to kinda keep at the front of your brain is the kind of importance with data accuracy and verification.

So always double-check your entries to prevent errors.

A lot of medical devices like vital signs machines, Pyxis's or OmniCells, which are kind of medication dispensers, and even EKG machines still they'll integrate into the systems as well too, which will automatically update the patient records in real time. So the data that you input, must be kind of a top priority as far as the accuracy just to ensure that all members of the health care team have the most, like, up to date information. Right? Everybody's gonna kinda be working off of this single patient's chart. And so, everybody's gonna be, kind of reacting and acting according to what the data is that's being put in there.

Yes. Absolutely. Absolutely.

And, you know, anything you know, it definitely improves the patient care, but can also save us time. Right? So documenting in real time, meaning, you know, you do something, you chart it.

And then that way, you know, it does prevent backlogging, relying on your memory to remember to chart something so it helps prevent things, from being forgotten, and just keeps that, data the most accurate as possible.

Yeah. We did just get a question that sorry to interject.

No. Go for it. But we just got a question, and this might be, you know, something good for us to cover too, from Alan.

They had asked, can we access the EMR flow sheet at home?

That's a great question.

Yep. Great question. And so I will say no. And, you know, that's kind of leading into one of our next topics. So we will get to that, but I will say, no. You cannot as the nurse.

I will say that the doctors, nurse practitioners, yeah. Right. They can have access, just so they can put orders in, from home if they're not at the facility. Right?

Yeah.

Like like Ashley was saying, we were actually that was a great question because it was actually what we're about to jump into, which is kind of the patient privacy, respect for the patients', secure information.

So this is, again, another best practice is following what we have here in the states is which is HIPAA regulations.

HIPAA ensures that patient health information remains confidential and protected from unauthorized access. Right? So audits are conducted regularly, and health care professionals are, only allowed to access these records of patients under their direct care in the facility on the unit. Right? This just minimizes in the risk of, even if you're at home. Right? A family member or somebody else, seeing the information, purposefully or unpurposefully.

Yep. Absolutely. And some of you guys may be thinking, like, what is HIPAA? Right?

And so it kinda sounds like HIPAA if you think about it.

And so, I'm curious though how many of you guys have heard of HIPAA.

And if you guys haven't, totally okay. We're gonna talk about it a little bit, a little bit deeper. So it stands for the Health Insurance Portability and Accountability Act, and it's actually a US law here. And so this protects the patient health info from, or by enforcing privacy, security, and breach notification rules for the health care professionals and organizations.

It also ensures the info is kept confidential, prevents unauthorized access, and gives patients control over their own medical records. Right? So like Derek was saying, you know, it really is meant to protect the patient. Right? You know, technology does have its challenges.

And so having this law in place protects us as a patient, but also, you know, us as, you know, the health care professionals caring for these individuals.

Yep.

Yep.

And to kinda get back to the EMRs, another benefit of having the EMR, the electronic medical record, is easier access to patient records. Right? So we're not even just talking about directly the, things that they're on that unit for. We can access medical history, things like that. The entire health care team can view the charts instantly. And like Ashley said, even for physicians who maybe aren't working on-site, they can access that remotely.

Patients can also access their records, through their own, MyChart, which, Ashten will kind of give a little more details to. But this allows them to kind of schedule their own appointments and even message their providers from their own homes.

Yes. Yes. I freaking love MyChart. It is so convenient. And so, what MyChart is is a platform that allows you to see your own medical records.

And so I'm curious if anyone, you know, in the other countries have something similar or have even heard that that was possible.

So you can you know, with Internet access, you can see, you know, your a summary of your visit with your provider.

You can even message, like Derek said, non urgent questions to your providers, and they can get back to you.

Even lab work. You can see your own results kind of like, the screen right now. Super, super cool, really convenient. And MyChart is just just one platform that's used. They're not all facilities do take advantage of MyChart, but there are other ways that they can still give their patients access to their, medical records when they're not even, you know, at the facility.

But from the health care professionals' perspective, you know, EMRs do a really good job at streamlining communication.

Like, you could easily like, there's a message kind of, you know, feature in the EMR system where you can message people that you're working with. So you can message providers. You can message other nurses, nurse aids when you need them to help you with something. Even pharmacy, you can just quickly message them a question about something.

And on the it's called the MAR. So the medication administration record within the EMR system, even has, like, medication education for yourself, but you can also even print it and give it to your patient. Like, it's amazing. So definitely, it's it's a lot, but it's so many benefits.

Yeah.

Yeah. I agree. I love my chart. I use it personally.

I like how quick it is to access, any, like, results. Like, when I get my blood work done, I'm always, you know, interested to get everything back as quick as possible. So it makes it very convenient.

And we actually got a question in from Samuel.

He had asked, are there instances where health insurance agencies contact the nurse directly for a piece of patient information?

So I can take this one, Derek.

So, no, I will say they typically connect like, the way the health care system is here, it depends on your position, honestly. So say you're a nurse working for a health insurance, you know, company, that could be a little different. But as a bedside nurse, no. You will never come in contact with insurance companies.

There's whole other departments that manage those things.

Typically, like Ashten just was saying. Right? They would connect with the billing department of the hospital to ensure that, right, what they're saying is accurate on their end. But, no, the nurse would never be like Ashten said, unless you're working for the health insurance agency, the nurse would never have to be kind of, tasked with that role of providing those kinds of itemizations.

So First question.

Great question. Great question.

Another key benefit of EMRs is just improved efficiency and accuracy. Right? So EMRs reduce paperwork, eliminate handwriting errors, and ensure that charts don't get misplaced.

So I'm very curious if anybody in the chat can relate to this, but how many of you have ever kind of run into the unfortunate experience of trying to decipher a physician's handwriting?

Right? So, managers also monitor this documentation to ensure accuracy and timeliness. But, again, just having everything clear, concise on a computer screen typed out just ensures that there's no, errors or even gaps in communication.

Yeah. Absolutely. Ugh. I can't even think about trying to read some of the physicians' handwriting.

Oh, it's rough.

And so, you know, one of the most crucial, I think, benefits of EMRs is patient safety. And so, you know, and it's just you know, we're human. Right? Mistakes happen.

We kinda have to deal with it. But the EMRs are built to be a double check for us. And so they, you know, just lessen the chances tremendously, of human error.

So it provides, like, medication alerts.

It tells you or, like, flags allergy warnings, even, like, in real-time updates. Like, it's just fantastic.

And so it just again, just so many benefits.

Yeah. And while EMRs offer many advantages, there are there can be some challenges too, and we know that too. So some nurses might struggle with a learning curve, especially when you're transitioning from just paper charting. I know when I first started nursing, as an LPN, I worked on a psych facility, and it was all paper charting.

Right? And then I got my RN, and then I started on a tele floor, and it was all electronic. Right? And so it just kind of, needed to bend my brain a little bit to kinda get over that learning curve.

But, yeah, there is a learning curve, typically.

Yeah. And, Derek, I didn't even know that you had a previous like, you have experience with paper charting. That's wild.

Oh, yes. And reading those signatures and orders. Yeah.

Of course. Yeah.

And so it definitely takes time to adjust, with the system and even remembering, like, what to chart and where to chart it.

There are a lot of flow sheets, but it all comes together so beautifully, and it's just so helpful, for the whole all the departments involved, but also just to keep yourself organized.

And so, you know, with all technology, right, not just EMRs, but just technology in general, there are ups and downs. Definitely some challenges.

So with one of them and this is for I mean, we all have to update our phone sometimes. Right? So EMRs are no different. They do have system wide updates, and so it's considered, like, downtime. Typically, it's during night shift, for a few hours.

But that's how they have to update the system at some point. And so with hospitals, obviously, being twenty-four seven, they gotta schedule that time. And so, there's that kind of, I guess, annoyance, you could say. It's not very often, maybe once a year.

But there's also there's also that chance of, like, a slow connection or something if the, like, the the Internet is being weird at a facility or something like that.

But definitely, there are there are challenges. Right?

But I will say that, you know, it can even feel like you're at the computer a little bit more than you're even with your patient. And some really have a hard time adjusting to that because of, you know, the responsibilities that we have here, in the amount of charting we do.

It can sometimes be, I don't know what the word is, but kind of kind of a bummer for lack of a better word.

But just know that you your charting is helping your patient, and it's so critical and important to do it.

Yeah.

But while we're on the topic of, you know, some, you know, problems that they might encounter and the importance of documenting.

Nina asked a really good question about what if my patient speaks a language I don't understand.

How do you go about documenting that effectively and making sure that, you know, you're checking in with your patient and that the information is correct?

Yeah. No. That's an excellent question. I know I've run into it in the past myself too.

And hospitals are typically set up in a great way where they do have people of support who speak those languages as, you know, as a translator. Yeah. Yeah. Yeah. And and sometimes the you know, whether it's a physical person that can come, you know, whether it's on day shift, sometimes if it's after hours, they even have, a a translator on a stick is what they call it. But it's essentially like a deep screen on a, like, a stick with wheels.

And they're able little iPad.

Yep. Somebody remote, and you're you know, they're able to talk to the patient for you and, kind of relay the information back and forth just to ensure, again, not only that, the patient is able to communicate to you as the nurse, but also that the patient is, understanding of what's gonna be happening from their standpoint too. So there's kind of a two-part benefit to that.

Right. That's definitely important, making sure that the communication is clear on both ends.

A lot of nurses are tuning in from all over the world. So with that comes a lot of languages that are being spoken and, you know, coming over to the United States, where English, you know, is a second language to a lot of our health care professionals, I can definitely see why that is a big concern. So thank you so much for kind of breaking it down, letting them know the kind of support that they'll receive, you know, if they ever come across a scenario like this.

Yeah. Yeah. Of course. Of course. And to kind of key back into that too, while you all are waiting to kind of come and make this journey, right, it would be important to kind of develop those technical skills if you feel like there is a deficiency on your end.

Right? If you are only used to paper charting or if you have kind of minimal kind of computer skills, basic computer proficiency can kinda make transitioning to those EMRs so much easier. Right? So over time with repetition, you will become more efficient and more confident navigating those systems.

But I do suggest, you know, just kind of in this meantime, if you have the availability to do so, just brush up on those kinda computer skills, you know, whether it's basic or as, kind of in-depth as you feel like you need. This would be a great time to kind of, kind of put some kind of energy into that.

Yep.

And we're seeing a lot of questions come in the chat about the computer systems and wondering if, you know, there will be a computer for each nurse that's working or if they share, computer.

Yeah. Yeah. I will say, typically, a lot of the patient rooms come with a computer built into it. Right?

So, all staff members who kind of need to have access to that patient, they utilize that computer in the patient's room. I will say that's not always the case, though. And as Ashten said, sometimes the computers are down for system updates, things of that nature. So things do happen where that might not be the, you know, the case, in which case, you know, facilities do have computers kinda set up in little kind of pods in the hallways, kind of in their in between patient rooms so that the nurses can kind of float back and forth.

There is access to you know, it's not the expectation and nor would it be permitted for, you know, nurses, you know, to bring in their own personal computers to kinda navigate this on their own. There are these systems in place. Now granted yeah. A downside is sometimes you might have to wait for somebody, you know, who might have the computer before you.

And so you might have to wait for them to complete whatever documentation that they're doing. Right? And so, hey, maybe I'm just gonna go jump and see the next patient and see if they need anything for pain.

And then, oh, you know, I just completed that task, and the computer is now open, and I can kinda finish that back task. Right? So Yeah. I hope that kind of answers that.

Yeah and definitely, yeah. Just to add to that, I'm just kind of thinking back on my experiences on the units I've worked and it's just like, there's even a nursing station where there's computers. So in addition to the random ones in the hallway, there's nursing stations. Each patient's room typically has a computer, but there's even computers on wheels.

That's called, like, a Wow. So it's a workstation on wheels.

So trust me, you know, they can still all be taken at times, but you definitely have access to a computer, at some point for sure.

We call them COWS, computer on wheels.

Well, there you go.

Oh, I love that.

Yeah. Yeah.

Lots of acronyms that we use here in the US. Yeah.

I know. It's so funny.

So there are obviously challenges. Right? But the benefits of EMR usage and the technology we have here totally outweighs those challenges. And so we're consistently improving them with time. There's even, like, a whole nursing career path called nursing informatics that literally focuses on these things. So it's just wild how far we've come in just, like, a short amount of time if you think about it. I think EMR started maybe, like, twenty years ago, twenty-five years ago, something like that.

Yeah. No. And and to kind of, like, tie this all together for you all, because I know, right, there is a lot of there's so many questions regarding all of this. But just know that there are gonna be resources available to you at the facility for you to learn and adjust to the system.

Right? So, not to get too far deep in, you know, into the weeds in regards to all the questions you might have because you might do a bunch of research on Cerner, and it turns out your hospital operates off of Epic. And then that's a completely just different format from Cerner. Right?

So, just understand that your facility will ensure that they orient you appropriately to the EMR systems. And just like we kinda tended at on our side, if you feel kind of like there's a deficiency with computers in general, just kind of brush up on those things in the meantime. Right? Whether it's typing.

I always felt like one of the best things that I ever was forced to do as a kid was take a typing class.

But it definitely kind of paid off for me in the long run. But, again, there are just little kind of things that you can kinda your own hygiene that you can kind of do in these regards.

But just know too that your facility will ensure that they do support you and give you all the information needed for their system.

Yep. And, Derek, I have a question too.

Lucky had asked this, and I think it would be, you know, oh, really great for everyone else to kind of get this information as well. But with the different systems that they use, for instance, Lucky's working in Nigeria, and mentioned the system that her facility is using and wondering if it's the same globally or maybe if they're different, you know, in the US than they are in other countries. Could so could you maybe, you know, just provide some insight on that?

Yeah. No. No. No. So, short kind of thing of that is, hey. If you went into another facility that operated with Meditech, chances are at least the layout, the flow are gonna be somewhat similar.

I will say that even hospitals in the same city, who have you know, both are operating off of Epic, they might have different platforms, you know, different kind of, layouts of their own Epic, generally speaking. So Mhmm. Overall, having experience with Meditech will kind of give you some sort of understanding of how Meditech operates.

Will it be that exact same version when you get, you know, to whatever facility you have? I cannot promise that. And I would honestly probably assume that there might be some variations to it. Yeah.

But, yeah, there are variations even from city to city, state to state. Yep. With this, you know, epics, there are just different platforms, hospitals, or facilities that kind of purchase the kind of, you know, bells and whistles that they want for their kind of, institution, and everybody kind of operates independently in that regard too. So Yep.

Awesome. Well, thank you for giving a little more clarification on that. And, Lucky, thank you so much for submitting your question. It was a really great question.

Yep. Yeah. Thanks everyone for all the questions.

Yeah. For sure. For sure. And we like like, kind of Courtney was saying before. Right?

Ashten and I, we're part of a team here. Even when you come stateside, right, you're gonna kind of run into some questions and things like that. And us as nurses, we speak the same language as you regarding nursing. Right?

So, we're here as a support. Not only will the facility support you, but we'll be able to answer some questions that you might have as well too.