“Health informatics technology includes the electronics and information technology used during the course of patient care, a practice also known as clinical informatics” (Rouse, 2014). In order to organize and maintain a patient’s records, Robert Wood Johnson’s emergency department utilizes a crucial electronic medical record called ED PulseCheck. This advance software allows the unit to communicate, manage knowledge, mitigate error, and support clinical decision making in practice. This collection of information allows the interdisciplinary team to promote the best available care in a timely manner. Specifically for a nurse, it will allow us to document our focused assessments and vital signs, view physician orders, monitor labs and diagnostic
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Informatics was an important section of my clinical experience. In the emergency department, documentation creates an important baseline during the course of the patient’s treatment. Every patient required a triage assessment followed by an assessment after entering into the emergency room. From there, focused assessments were recorded based upon the presented problems. For example, one of my patients arrived with a chief complaint of shortness of breath; following this complaint, a thorough respiratory assessment was implemented. Upon auscultation of the lungs, I found inspiratory and expiratory wheezing. Along with this clinical manifestation, the patient also stated that they were in pain, had tachycardia upon auscultation, and tachypnea. Immediately after assessing the patient and determining their stability, my results were documented descriptively to the best of my ability. Most importantly, these documentations allow my healthcare team and I to monitor for the positive or negative outcomes during treatment. The words of wisdom that I was presented during nursing school is that if it is not documented, it didn’t truly happen. So therefore, I document every bit of nursing care that I
Informatics was an important section of my clinical experience. In the emergency department, documentation creates an important baseline during the course of the patient’s treatment. Every patient required a triage assessment followed by an assessment after entering into the emergency room. From there, focused assessments were recorded based upon the presented problems. For example, one of my patients arrived with a chief complaint of shortness of breath; following this complaint, a thorough respiratory assessment was implemented. Upon auscultation of the lungs, I found inspiratory and expiratory wheezing. Along with this clinical manifestation, the patient also stated that they were in pain, had tachycardia upon auscultation, and tachypnea. Immediately after assessing the patient and determining their stability, my results were documented descriptively to the best of my ability. Most importantly, these documentations allow my healthcare team and I to monitor for the positive or negative outcomes during treatment. The words of wisdom that I was presented during nursing school is that if it is not documented, it didn’t truly happen. So therefore, I document every bit of nursing care that I