Electronic health records play a great role in comprehensive health assessment. Basically, it refers to a digital version of a patient’s paper chart. Additionally, these records are real-time and patient centered hence they make information instantly available. They also ensure that information is secure thus only accessible by authorized persons. These record systems are built to go beyond standard clinical data collection thus are inclusive of a broader view of patient care. They help in comprehensive health assessment whereby they give nurses insight into the patient’s data. This includes activities like observation and measurement of vital signs. Therefore it provides a complete record of physical examination.
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TECHNIQUES USED IN COMPREHENSIVE HEALTH ASSESSMENT
When nurses perform comprehensive health assessments, they use four major techniques. Firstly, inspection is the most frequent method. This technique involves the search of health problem indicators such as abnormal sounds and odors. It involves inspection of skin color, bruises, or rashes. Secondly, there is auscultation which involves listening to sounds of the abdomen. It involves placing the diaphragm of a stethoscope on the bare skin of a patient this listening to the sounds. Thirdly, palpation whereby, nurse apply pressure on different parts of the patient’s hands. This, therefore, allows them to assess for texture and pulses. Lastly, percussion involves the search for a patient’s level of discomfort. The results from these tests are stored in form of electronic health records.
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ADVANTAGES OF ELECTRONIC HEALTH RECORDS
Electronic health records help to provide accurate, updated, and complete information about the patient thus reduces errors in data. They also enable quick access to patient’s records thus ensuring more coordinated and efficient care. Additionally, they improve patient and provider interactions and communication, therefore, enhancing health care convenience. Also, they help nurses to effectively conduct comprehensive health assessments since they reduce medical errors and provide safer care. Moreover, it enables safer and more reliable prescribing of medication to patients. Nevertheless, it enhances the privacy and security of patients’ data. Lastly, it promotes legible and complete documentation. This, therefore, ensures accurate and streamline coding and billing
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