Lesson Plan: Electronic Medical Charting
NUR/588
May 19, 2014
Bianca Needham
Professor Gail Wolf

Identification of the educational need and rationale: The implementation of electronic documentation for medical records, medications, and nursing flow sheets has replaced the existing paper documentation and is currently the educational need with the highest priority for the Emergency Department at the University of Massachusetts Memorial Medical Center. In a continuous care operation, it is critical to document each patient’s condition and history of care, to ensure the patient receives the best available care. The medical record documents the care of the patient and can immediately be accessed, updated, and passed among the interdisciplinary team of caregivers. The Emergency Department is the initial passageway to the hospital for most patients. Electronic documentation is a patient’s health information including medications, allergies, past and present illnesses, and family history can be gathered upon their initial presentation and up-to-the minute revisions can be made by the healthcare team throughout their hospital stay. The Electronic Medical Record/Charting can be designed to hold collaborative information from all providers that are involved in the patients’ care. With each subsequent visit thereafter, the patient’s demographic, insurance, and health history database will automatically pre-fill the electronic template alleviating nurses of time restraints associated with paper documentation. This allows for quick updates to the patient’s profile if necessary. Patients may suffer drastic consequences when a chart is misread, lost, or switched accidentally. Electronic documentation provides chart legibility, clarity, error minimization, speed of accessibility, and up to the minute progression of care provided which are distinct advantages over