Electronic Record Keeping in Nursing and Healthcare: An Analysis

This essay examines the evolution of record keeping in nursing and healthcare, contrasting electronic health records (EHRs) with traditional written methods. The author argues that while EHRs promise efficiency, their lack of universal accessibility renders them a luxury rather than a necessity. The discussion explores the advantages of EHRs, such as organized storage and improved healthcare service, but also highlights the barriers to their implementation, including cost, resource limitations, and organizational factors. The essay references studies that identify micro, meso, and macro levels within healthcare, revealing how various social, professional, and behavioral factors impede EHR adoption. It concludes that a complete shift to electronic systems without proper training and accessibility could be counterproductive, advocating for a balanced approach that incorporates EHRs while acknowledging the continued value of written records. The essay emphasizes the need for improved training and accessibility to ensure that all levels of medical service providers can effectively utilize EHRs.

Running head: ELECTRONIC RECORD KEEPING IN NURSING AND HEALTHCARE
ELECTRONIC RECORD KEEPING IN NURSING AND HEALTHCARE
Name of the Student
Name of the University
Author Note

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Introduction
Recent developments in technology has influenced the field of healthcare in more
ways than advanced medical instruments. In nursing and especially in the narrow sector of
medical record keeping, electronic health/medical records are seemingly overtaking the
traditional means of record keeping (Nielsen 223). It might indicate progress and
development but a few recent studies have indicated that the situation of EHR/EMR is
juxtaposed between complete overthrow of traditional record keeping and absolute
dominance of EHR technology in the medical field. This essay attempts to elucidate the
necessity of writing in medical record keeping and how the efficiency in record keeping
promised by EHR technology is not accessible for everyone in the field.
Thesis Statement
Advances in Electronic Health Records might promise to make record keeping
simpler and efficient but the lack of accessibility by all individuals concerned, still renders it
a luxury technology more than a necessity over written records.
Discussion
Electronic Medical/Health Records are patient information that are digitally stored on
a computerized system (Ajami and Bagheri-Tadi 129). The advantages which are kept in
mind while designing EMR systems include ease of accessibility, organized storage of patient
information, reduced use of complicated paper based recording system and effective
deployment of quicker and better healthcare services to patients. These systems can keep a
record of a patient’s health across multiple domains of medical science and can therefore
prove to be significant over the traditional systems of handwritten records by keeping
information of a patient’s all possible medical problems in one secure location.

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Despite such ease and efficiency provided by EMR systems, not everyone in the field
of nursing and healthcare can access such a system. The Study by Nambisan, Kreps and Polit
(8) on the factors influencing the use of EMR systems in healthcare, has identified healthcare
in itself to work under three main levels namely Micro, Meso and Macro. The study indicates
that at a micro level, individual physicians or small dispensaries and health centers are unable
to access the services of EMR because of the cost as well as lack of required resources,
redundancy of EMR in small health centers, lack of communication and trend of use
(Nambisan, Kreps and Polit 3-8). While at the meso or organizational level, the factors that
stand as impediments to the implementation include primarily the inner workings of the
organization that prevents the management from incorporating newer technologies in the
system, the macro level is identified as the only one where direct implementation of EMR
systems has been noticeably promoted by the government alongside intense marketing
through multiple digital media.
This division indicates that despite its efficiency and reliability, EMR implementation
is limited by a variety of social, professional, cultural and behavioural factors. Ajami and
Bagheri-Tadi (131-133) had identified several other factors that pave the path for the
adoption of EMR technology. Many of these factors like inability to use a computer, lack of
time, interference with patient-physician relationship, security, accessibility and sharing
protocols etc do provide genuine reasoning in favour of why physicians are more suited to
stick to the traditional writing based record keeping techniques than shift to EMR technology
(Fernández-Alemán 544).
Conclusion
Traditional means of record keeping in healthcare services and nursing might seem
like a lengthy process, but shifting to a complete electronic system might prove equally

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counterproductive without proper foresight (Ajami and Bagheri-Tadi 129). Specialised fields
in medicine involve specialised doctors who attend numerous cases everyday with a set habit.
Shifting their environment to something uncommon might hamper their workspace comfort.
EMR introduction can be made feasible through proper training and better accessibility
provided to all the levels of medical service providers.

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References
Ajami, Sima, and Bagheri-Tadi Bagheri-Tadi. "Barriers for adopting electronic health records
(EHRs) by physicians." Acta Informatica Medica 21.2 (2013): 129.
Fernández-Alemán, José Luis, et al. "Security and privacy in electronic health records: A
systematic literature review." Journal of biomedical informatics 46.3 (2013): 541-562.
Nambisan, Priya, Gary L. Kreps, and Stan Polit. "Understanding electronic medical record
adoption in the United States: communication and sociocultural perspectives." Interactive
journal of medical research 2.1 (2013): e5.
Nielsen, Søren Beck. "Medical record keeping as interactional accomplishment." Pragmatics
and Society 5.2 (2014): 221-242.