EHR History
This was the primary purpose of early healthcare records
What is teaching and reference
This type of digital record is created by a single provider and does NOT follow the patient across systems
What is an EMR
Improving this is the primary purpose of an EHR.
What is improving health outcomes
Early EHRs modeled themselves after this outdated type of healthcare documentation, causing inefficiency.
What are paper charts?
This term refers to consistent language used across nursing diagnoses, interventions, and outcomes.
What is Standardized Nursing Terminology (SNT)?
This Founding Father kept detailed patient casebooks in the 18th century
Who is Benjamin Rush
This type of record is interoperable and contains data from all providers involved in a patient’s care
What is an EHR
Nurses often complain that EHRs have too many of these, slowing them down and interrupting workflow.
What are clicks or alerts?
Adding more tabs, buttons, and windows often leads to this user-experience problem.
What is poor navigation?
This is the major benefit of standardized terminology within EHRs, allowing different systems to communicate.
What is interoperability?
This Mayo Clinic physician created the first clinical record-keeping system with patient numbers in 1907
Who is Henry Plummer
Directed, query-based, and consumer-mediated are the three types of this electronic information-sharing system.
What is Health Information Exchange (HIE)
Poor EHR usability has been linked to these two major nursing-related consequences.
What are nurse burnout and decreased patient satisfaction?
Poor usability in EHRs can result in errors such as incorrect dose or route of this.
What is medication administration?
This minimum data set, established in 1984, includes nursing diagnoses, interventions, and outcomes.
What is the Nursing Minimum Data Set (NMDS)?
This 2009 federal act provided incentives for hospitals and providers to adopt EHR technology
What is the HITECH Act
This type of personal health record allows the patient to manually enter data themselves.
What is a standalone PHR?
This nurse-led intervention improved usability by embedding policy hyperlinks directly into the EHR (Lyerla et al., 2022).
What is adding embedded policy and procedure hyperlinks?
Some EHR vendor contracts forbid this action, limiting transparency and improvements.
What is sharing screenshots or publicly criticizing the system?
NANDA-I, NIC, and CCC are examples of this type of terminology used at the point of care.
What are interface terminologies?
This 2016 Act emphasized interoperability and required Certified EHR Technology
What is the 21st Century Cures Act
This type of personal health record is linked to an organization’s EHR and displays labs, vaccines, and reminders.
What is a tethered (connected) PHR
This national nursing organization urges nurse involvement in EHR design and implementation.
What is the American Nurses Association (ANA)?
The gap between workplace technology and this type of technology contributes to slow innovation.
What is consumer technology?
LOINC and SNOMED-CT are examples of this type of terminology used for standardized communication.
What are reference terminologies?