UCARE Why Electronic Medical Records?
Nursing is an information processing activity. Registered Nurses have clinical skills, and use and develop knowledge that leads to improved health and
quality of life. Because of this, student nurses need to become sophisticated in using technology; both to support direct patient care, and to manage health information.
Electronic documentation is an expectation of students' clinical performance, and managing information is part of the clinical learning objectives in their courses.
Accurate, comprehensive, charting has been emphasized since Florence Nightingale’s time, in the mid 1800s. Nowadays, it's become increasingly important, and in fact, mandatory, the documentation be complete and accurate.
So, why do nurses chart?
The primary reason for charting is communication, both with other nurses, and with other clinicians. Information needs to flow across the continuum of patient care, from admission to discharge, and even across multiple episodes of care.
Charting is used for clinical decision making; many of our clinical decisions include both the history, as well as the current information, in order to make a good decision. The chart is also the legal record; there's a prevailing wisdom that says, "it's not done until it's charted," which helps nurses remember that the chart is the legal record.
Charting is also used for reimbursement from insurance companies.
The information from a chart can be aggregated across multiple patients, to evaluate process and outcomes of care. It's used for local quality improvement studies to improve the care within a single area. It is used in formal research, and the knowledge gained is used and fed back to clinical care to create "Evidence Based Practice." The information is also used in education, for public health purposes, and to establish policy.
Health care is rapidly moving toward electronic health records.
Benefits of electronic charting:
- Improved access too and timeliness of data
- Improved privacy and security safeguards
- More consistent documentation
- Improve outcomes and reduce errors
UCARE Academic Education Solution (AES)
UCARE AES is a fully function electronic health record that has been customized for educational purposes. It is the academic version of Cerner's electronic chart that has been modified for teaching, and has been populated with simulated patient data. UCARE AES serves as a high-fidelity clinical information system simulator, which allows instructors to teach patient information management concepts, content, and process.
UCARE AES might not match, exactly, the look and layout of the clinical information systems used in the various teaching hospitals used for clinical rotation --every place has a slightly different medical record. This allows instructors to teach techniques and expectations, instead of teaching brand reliance.