Electronic Medical Records (EMR) For Nursing Documentation: A Concept Analysis

DOI

10.2991/978-94-6463-467-9_14How to use a DOI?

Keywords

Concept Analysis; Electronic Medical Records (EMR); Nursing Documentation

Abstract

Electronic medical records (EMR) have revolutionized the healthcare landscape as a digitized rendition of conventional (paper-based) medical records, prominently adopted across various health facilities. These digital archives encapsulate a plethora of records and information meticulously curated by healthcare personnel within the facility, primarily aimed at facilitating the process of diagnosing and treating patients’ health conditions. Nursing documentation, an integral aspect of healthcare practice, entails the comprehensive recording of all activities pertaining to the nursing process. It serves as a vital tool benefiting not only clients but also nurses and collaborative partners. The process of documenting nursing activities encompasses a series of interconnected actions that form an uninterrupted cycle spanning various stages including assessment, nursing diagnosis, intervention, implementation, and evaluation. This manuscript aims to conduct a thorough concept analysis of electronic medical records (EMR) nursing documentation, delving into its antecedents, attributes, and consequences, supported by empirical references. Additionally, the elucidation of concepts will be augmented through the utilization of case models, borderline instances, and contrary cases. Furthermore, the quality of nursing documentation will be assessed employing the D-Cacth instrument, contributing to a deeper understanding of its efficacy and implications within healthcare settings.

Copyright

© 2024 The Author(s)

Open Access

Open Access This chapter is licensed under the terms of the Creative Commons Attribution-NonCommercial 4.0 International License (http://creativecommons.org/licenses/by-nc/4.0/), which permits any noncommercial use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license and indicate if changes were made.

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TY  - CONF
AU  - Muhammad Sulaiman
AU  - Arifudin Arifudin
AU  - Rib’hanul Hakim
PY  - 2024
DA  - 2024/07/22
TI  - Electronic Medical Records (EMR) For Nursing Documentation: A Concept Analysis
BT  - Proceedings of the 2nd Lawang Sewu International Symposium on Health Sciences: Nursing (LSISHS-N 2023)
PB  - Atlantis Press
SP  - 147
EP  - 163
SN  - 2468-5739
UR  - https://doi.org/10.2991/978-94-6463-467-9_14
DO  - 10.2991/978-94-6463-467-9_14
ID  - Sulaiman2024
ER  -