Month: October 2021

Electronic health records (EHRs) support that documentation with data can help to enhance patient safety, maximize efficiency, and evaluate care quality. It helps to provide accurate, up to date, and complete information about patients are the point of care. It allows for quick easy access of patient information and health status. Not only will EHRs help nurses on admission with help in seeing past medical history and other pertinent information, but it will help throughout their shift by giving medication administration reminders and potential drug interactions. EHRs allow more effective communication between those in the health care team. It will give everyone the same information on each patient to look at and allows the ability to write notes regarding the patient’s care that everyone looking at the chart would have access too. Basically, utilizing EHRs will keep everyone on the same page which would help promote adequate, wholesome care and positive patient outcomes.

Health information exchange (HIE) allows doctors, nurses, pharmacists, other health care providers and patients to appropriately access and securely share a patient’s vital medical information electronically. It improves the speed, quality, safety, and cost of patient care. Some common challenge that clinical work flows may present include updating patient care plans when multiple providers are caring for them, piecing together medical history, readmissions due to lack of communication and engagement, and gaps in patient information which increases the change of creating a care plan that can cause adverse effects. HIE can help to solve these solutions by creating a better, safer, and easier solution for the healthcare environment. It does this by improving communication and care planning among healthcare providers during transitions of care, providing assurance that care teams have accurate information at point of care, enabling improvement in both quality and cost outcomes through reduction in duplicate testing, medical complications, readmissions. HIE also will assist in targeting care for patients with chronic diseases, risk for future utilization, and quality measure gaps to put care plans in place more quickly. Overall, the evolution of where we are now with HIE has great improved communication within the healthcare system and therefore, patient outcome.

Learning about Electronic Health Records and HIE will help me to enhance the thoroughness and accuracy of my charting throughout clinical experiences. I did not know that what is charted within my facility can be seen by the other providers of my patients. This will improve the overall quality of my charting because gaps in the EHRs can negatively impact a patient’s plan of care. I will also utilize the EHRs during my nursing career to help make sure that I am efficient in caring for my patients. It will allow me to not forget to administer any medications and be sure that all medications given are compatible with each other. EHRs will also help me to know my patient before actually meeting them. It allows me to make a rough outline of my plan of care for the day for each patient. At the beginning of each shift, I will be sure to look at each my patient’s EHR to prioritize each patient’s needs and see which patient that I should check in with first. EHRs will be extremely beneficial to my future nursing career and I am excited to be able to learn even more about it.

Trauma is an emotional response to a terrible event that has happened in someone’s life. This can range from an accident, rape, or a natural disaster. Trauma can have lasting effects on your mental, physical, and emotional health. It can affect how your feel about yourself and others and cause increased risk of developing a mental health condition including depression, anxiety, or PTSD. Trauma can affect your physical health by triggering endocrine and immune problems leading to increased risk of chronic illness including chronic autoimmune illnesses, heart attacks, diabetes, strokes, or cancer. It can result in many physical reactions including fatigue or exhaustion, nausea, vomiting, dizziness, or insomnia. Spiritual well being can be affected because the individual could feel that they are being punished or abandoned by God, lose faith, decrease participation in religious activities, or feel a loss of meaning and purpose for living. Social well-being can be effected because it can cause an individual to withdraw from family and friends leading to isolation. The emotional distressed experienced can also make it difficult to relate to others.

Adverse childhood experiences (ACES) are potentially traumatic events that occur in a childhood and can include violence, abuse, and growing up in a family with mental health or substance use problems. ACES can have several long term impacts of adverse childhood experiences. It can change the brain development and affect how the body responds to stress. Additionally, ACES are linked to several chronic health problems, both physical illnesses and mental illnesses. It can cause chronic health conditions including depression, COPD, asthma, kidney disease, stroke, coronary heart disease, cancer, diabetes, and obesity. Health risk behaviors that can result from ACES include smoking, drinking, and other forms of substance abuse. Socioeconomic challenges that may be impacted include unemployment status, education level, and health insurance. Preventing ACES can help children to thrive and potentially prevent the chronic health conditions, risky behaviors, unemployment, low education levels and prevent ACES from being passed on from one generation to the next.

I will apply the Trauma- Informed Care (TIC) principles to my future nursing practice to help to prevent and identify ACES. I will anticipate and recognize current risks for ACES in patients who are children and understand the history of ACES in adults. I will establish rapport with my patients so that I am able to fully engage with the patient and get all of the information that I would need to properly care for the patient. I will respect the patient and their boundaries on what they are comfortable talking about. Additionally, I will treat my patients as actual people who I care about by taking my time with them and allowing them to feel heard and valued. Allowing the patient to be in control of these difficult conversations can also help. Overall, being aware of TIC in my practice will help to prevent and identify ACES in my patients.