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Electronic Health Record

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Which are primary functions of the electronic health record? Provides patient information for planning careThe electronic health record enables the use of accurate, up-to-date patient- related information to help nurses plan care. Provides interdisciplinary documentation reviewThe electronic health record provides an interdisciplinary approach to patient care by allowing all health care providers to see patient information for better patient care decisions. Allows access to decision support tools for ease of careThe electronic health record allows access to all patient care areas, often as dashboards, for help in health care decision-making. The new nurse is learning to use the electronic health record (EHR). Which knowledge and skills must nurses have to effectively use the EHR? Computer literacyUse of the EHR requires basic computer literacy or understanding how a computer works. Lack of computer literacy could have safety, security, and accuracy implications. Password protection and securityData security is a major component of the EHR requiring individual passwords that are not to be shared. Understanding password protection and security strengthens the safety and security of patient information. Communication managementThe EHR allows for interdisciplinary communication ensuring that patient needs are met, care plans reflect current information, and cost-containment measures are effective, such as not repeating diagnostic tests already performed. The nurse is caring for a patient admitted with opioid use disorder. Match the electronic health record benefit with the step used in patient care. Assessing opioid blood level System connectivity Determining health care needs Point-of-care information Providing external provider support Remote access Using CPOE to manage prescriptions System integration The nurse made an error in documenting a patient's care. Which method would the nurse use for correcting a documentation error in a paper chart? Place the nurse's initials beside the error, and draw a line through the error.


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