Qualitative Care using Electronic Health Records (EHRs)

Qualitative Care using Electronic Health Records (EHRs)

The introduction of Electronic Health Records (EHRs) has played a major role in the present healthcare environment, helping healthcare providers keep track of store and access patient information efficiently. In the nursing world, EHRs help to facilitate communication among healthcare providers, keep patients safe, and boost the quality of the care they receive. In county health department clinics, it is particularly vital to have accurate records in the EHR as the information provided can impact the treatment of patients, as well as public health policy and planning. Therefore, the nurse’s role is to ensure that all patient information is recorded accurately and consistently, to allow the patient to receive optimal care and for evidence-based practice.

Accuracy Matters

Example of Inaccurate Data Entry in EHRs

The inaccuracies of data in EHRs can affect patient care and public health data in a wide way. For example, if a nurse incorrectly writes that a patient has been vaccinated, but they have not, the county health department may report a rate of immunizations that is not accurate. This can lead to problems with community health surveillance as the healthcare provider may believe that immunization levels in the community are higher than they are. This can leave communities more susceptible to outbreaks of infectious diseases because of lower-than-optimal immunization rates (Anita Walden_ et al., 2023). When documentation is incorrect, it can have a bearing on the safety of a particular patient. Allergic information is incorrectly stored in the patient’s EHR, and he/she might get a drug that causes an acute allergy. Therefore, the secure and accurate public health record keeping and patient safety is crucial to good EHR documentation.

Keeping accurate records of EHRs.Measures for proper documentation in EHRs.

One-way nurses can ensure that information is accurate is to double check patient data before entering it into the EHR system. To prevent documentation errors, the nurse should verify patient identifiers and medication information, allergies, and assessment findings. Verifying data prior to entering it into the system helps to ensure data reliability and patient safety. Another approach is to “write as you go” while providing care to the patient. Real-time documentation helps to minimize the risk of missing out on key points or taking in wrong data at a later stage. Plus, it facilitates communication between health care providers, and the most current medical information will be available to the health care team.

Data Drives Decisions

Historical Patient Data can be used to create a Nursing Care Plan. A Nursing Care Plan can be developed from Historical Patient Data.

These patient history data can be accessed in the EHR when a patient is readmitted to the hospital and can be used to develop effective nursing care plans by health nurses. If, for instance, the patient with diabetes comes back to the clinic with a poor blood glucose level, the nurse could consult the previous EHRs to see if there are any trends. The nurse can review previous lab data, medication compliance, diet and previous hospitalizations (Farford et al., 2026). Based on historical data, the nurse can develop a modified nursing care plan, centered upon the areas of enhancing patient education, improving blood glucose monitoring, improving dietary management, and improving medication compliance. The historical EHR information can assist nurses make knowledgeable clinical decisions and provide individualized patient treatment.

The impact of EHR Data on better patient and population health outcomes.

A major use of EHR data is to help manage chronic disease, which impacts patient outcomes. Healthcare professionals can track and identify trends in their patients’ health, such as hypertension, diabetes, or asthma and act at an earlier stage when the complications occur. Early intervention could be able to decrease hospitalization and enhance patient health. Additional benefits of EHR data that can improve population health would be disease monitoring and prevention. Disease outbreak, vaccination rates, health community trends can be tracked using information from EHRs. This data can be used to inform prevention programs and help health systems optimally distribute health resources to enhance health in the community (Wang et al., 2025).

Standardization Speaks Volumes

Standardized Nursing Terminology is a set of codes which document specifically for the nursing profession.

Standardized nursing terminology as described by Bertocchi et al. (2025) is using a common and universally accepted language among nurses for communicating patient care in EHR. Common or standard terminology, such as Nursing Outcomes Classification (NOC), Nursing Interventions Classification (NIC) and NANDA International (NANDA-I) helps to communicate patient condition, nursing interventions and patient outcomes clearly and consistently.

The importance of using standardized nursing language to document EHRs.

Standardized nursing language in EHR documentation helps to show the unique value and contribution of nursing practice to care. The use of language helps healthcare providers to share information on the patient’s assessment, interventions, and outcomes when providing care in any healthcare environment. Furthermore, standardized nursing documentation promotes communication among health care professionals and continuity of care. The uniform use of language facilitates the interpretation of patient information, analysis and communication among the members of the healthcare team, including nurses. Standardized terminology also enables healthcare organizations to calculate the contribution of the nurses to the results achieved by patients and promotes evidence-based healthcare practice and research.

Conclusion

EHRs can have a significant impact on patient care, patient safety and public health. Having accurate documentation in EHRs helps reduce medical errors and ensure reliable healthcare data. Historical patient data enables nurses to make informed decisions and create care plans tailored to each patient, while EHR data helps to enhance patient and population health outcomes. Furthermore, the standardized nursing language facilitates communication among healthcare providers and highlights the role nurses play in providing safe and effective patient care. With healthcare technology changing rapidly, it is important for nurses to keep advocating for accurate, timely and standardized EHR documentation for improved health outcomes.

References

‌Anita Walden_, A. W., Zozus, M., & Pieper, C. (2023). Comparing the Accuracy of Health Record Data and Self-Reported Data. https://doi.org/10.25302/03.2023.me.140922573

Bertocchi, L., Petrucci, C., Masotta, V., Marcotullio, A., Jones, D., Lancia, L., & Dante, A. (2025). Standardized Nursing Terminologies and Electronic Health Records: A Secondary Analysis of a Systematic Review. Healthcare, 13(16), 1952. https://doi.org/10.3390/healthcare13161952

‌Farford, B. A., Hurd, J. K., Crick, J. L., Salinas, M., Nguyen, C. Q., Bertasi, R. A. O., Zapp, D. G., Janitz, T. M., & Pujalte, G. G. A. (2026). Impact of Dedicated Nurse Time on Electronic Health Record (EHR)-Based Diabetes Quality Measures: A Pre–Post Observational Study. Cureus. https://doi.org/10.7759/cureus.105341

‌ Wang, S.-H., Lee, Y.-L., Su, E. C.-Y., & Tsai, C.-H. (2025). Role of health information technology in enhancing chronic disease management: a scoping review protocol. BMJ Open, 15(6), e093220. https://doi.org/10.1136/bmjopen-2024-093220

 

 

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Unit 2 Assignment Directions: Mastering Electronic Health Records (EHRs) for Quality Care

Scenario

Imagine you’re a registered nurse working in a county health department clinic. You’re responsible for documenting patient care in the electronic health record (EHR) system. Create a 4-7 minute video in which you are responding to the following prompts. Please use this unit’s learning resources and your own scholarly resources to complete this assignment. Please review all learning resources provided in this unit before starting this assignment. See the grading rubric for this assignment.

  1. Accuracy Matters:
    • Provide an example of how inaccurate data entry in EHRs for patient care in a county health department clinic impacts public health data.
    • Explain two strategies you can employ to ensure the accuracy of information that you data enter in the EHR system.
  2. Data Drives Decisions:
    • Provide an example from your nursing practice of how you can utilize historical patient data from the EHR to develop a new nursing care plan for a readmission when chronicling care.
    • Discuss two ways EHR data can be used to improve patient/population outcomes.
  3. Standardization Speaks Volumes:
    • Define standardized nursing terminology in the context of EHRs.
    • Explain how using standardized nursing language in your EHR data documentation reflects the unique value and contributions of nursing practice to patient care.

Please use the UMGC Microsoft Teams or Stream application or any other video software to record your video. Be sure to include your face in the video with audio.