Patient Charting in the United States

As nurses, we all know of Florence Nightingale. She is, in a way, the mother of nursing. However, in 1837, Linda Richards started to have the physicians write down the orders, and she started to create charts in order to track the patients’ medical history. Due to these efforts by Richards, we now have advanced systems across the world related to patient record keeping. In the US, the way we chart on patients and their medical records can vary depending on facility, and region. The most popular ways of keeping records include Electronic Medical Records/Electronic Health Records (EMR/EHR) and paper charting. Depending on what you are used to, you may be familiar with one or both methods already; however, if you are unfamiliar, these two different styles may seem complicated initially. With time and practice, charting on patients will become second nature to you.

Electronic Medical Records

In the US, one of the most common types of charting, in most facilities, is by utilizing an Electronic Medical Records/Electronic Health Records (EMR/EHR) system. If you are not familiar with an EMR, it is a computerized system that allows you to access patients’ records and updated their data. Some common EMR systems that are used in the US are Epic, Cerner, and MEDITECH. The EMR will be facility/company specific, and they should be password protected. You will have access to information like the patients’ medical history, treatment plan, and past procedure. You will also be able to document the care you have provided during your shift. Each facility will have certain policies that help dictate what will need to be charted within the EMR. As you get oriented to the hospital, your preceptor will ensure you understand how to use the system properly. These systems go through upgrades and changes every so often. The updates hopefully allow for a better charting experience. When the system makes these updates, it is also a learning curve for everyone using it, so you won’t feel alone in the process.

Paper Charting

Another type of charting that is a little less common in the US is paper charting. Some advantages to paper charting are that it is more cost-effective, power outages have no effect on the charting ability, and it is easily customizable for the patient population. Paper charting is essentially the same thing as an EMR. The main differences in a paper chart vs. EMR is it is all handwritten. There are pros and cons to this depending on what you are familiar with to and how you personally like to track information. Paper charting can also be used in combination with EMR. The main charting might be handled electronically; however, there may be aspects of health information that is tracked within paper records.

HIPPA

Many countries have a certain standard that is held regarding how they keep their citizens health records and information private. The policies and standards for the US regarding patient health information privacy is outlined through the Health Insurance Portability and Accountability Act, or more commonly known as HIPAA. HIPAA was enacted in 1996. Due to these rules set in place for administrations and health care employees, our patients’ information is kept safe. Before moving to the US, it is a good idea to become familiar with the basic concepts that HIPAA embodies. This will help with the transition as you become a US nurse.

Tying it Together!

No matter how your new place of works tracks patients’ records, you will be able to adapt and thrive. The team at RN Staffing USA knows that this can seem like information overload; however, we promise any new skill can be a challenge to understand at first, but once you have mastered that ability, you will be more marketable and better prepared for your future affairs as a nurse. Every new EMR or paper chart you come in contact with (and master) will only help accelerate you to the next level in you career!