QUESTION ONE
An Electronic Health Record System is a system that store all patient data in one place,
allowing healthcare providers to easily access comprehensive patient histories. Centralizing
patient information facilitate better patient care and support workflow. Thus, proper design
will ensure the system supports my clinical workflows and patient care. A nurse or midwife is
the primary end-user who captures and document patient data. Therefore, a nurse’s or
midwife’s contribution to the design phase of a new Electronic Health Record System such as
LHIMS or GHIMS is critical. During the design phase of the EHR system, I would suggest
the system entails these key areas:
Clinical Workflow Alignment/Mapping and Analysis: The system should incorporate an
accurate account of existing daily clinical nursing and midwifery workflows and routines—
such as patient admission, assessment, monitoring and discharge; vital sign capture; antenatal
care; labor and delivery; medication administration; postnatal care; newborn care; and shift
handovers — to ensure that the system captures these step-by-step real-world clinical
processes.
Clinical Content Documentation and Template Development: The system should allow easy
nursing-specific documentation templates, flowsheets and forms for antenatal visits, labor
progress notes, pantograph, postnatal assessment, newborn assessment, immunization
records, vital sign summaries, nursing care plans, and discharge summaries. Design of
standardized templates containing essential clinical fields using familiar terminology and
formats will ensure complete, accurate and reliable documentation to improve clinical
decision–making and continuity of care.
Clinical Decision-making Support Integration: The Electronic Health Record system should
incorporate clinical decision support tools such as automated alerts for abnormal vital signs,
high risk pregnancy indicators and medication interaction warnings or reminders for overdue
nursing interventions and antenatal screening tests.
An Electronic Health Record system should contain features for identifying critical safety
information like allergy alerts, high-risk pregnancy flags, previous obstetric complications,
medication interaction, dose calculations and alerts for medication schedules, lab results, and
patient deterioration. Integrating these critical safety features into the system design will
support timely interventions and minimize common clinical medication errors, thus
enhancing or promoting patient safety.
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User-Friendly Interface Design: An Electronic Health Record system design should
incorporate an intuitive interface whereby the layout of screens prominently display high-
priority information such as allergies and recent vitals that are easily accessible with minimal
checks. Given the mobile nature of nurses or midwives, a mobile-friendly interface or tablets
for bedside documentation will guarantee mobility and accessibility, making it easier to
access, navigate and update patient information. If the system is not easy to use, clinicians
may spend more time with the computer than with patients.
Confidentiality and Ethical Care: An Electronic Health Record system design that protect
patient privacy and confidentiality especially in sensitive areas like reproductive health.
Maintaining confidentiality builds patient trust and complies with professional ethical
standards in nursing and midwifery practice. The system can also include features that allow
patients to access their records, medication schedules, and educational materials; which
would empower them and improve adherence. Patients empowered with access to their
records and schedules are more likely to adhere to treatment plans.
Integration with Existing Systems: Seamless integration with lab, pharmacy, and radiology
systems would reduce data duplication and errors, ensuring comprehensive patient records.
Integration with other systems ensures all patient data is up-to-date and accessible,
facilitating holistic care and improved care coordination.
Training Support and Feedback Mechanism: Adequate training and continuing support are
crucial. It is essential hands-on training sessions, simulations and regular usability testing are
conducted for feedback to identify pain points. I would recommend to. A built-in feedback
mechanism for users to report issues on the best practical tools (hardware and device) for the
environment—such as tablets for mobile bedside care or workstations on wheels or suggest
improvements would instill confidence in using the system and ensure that the system
evolves with changing healthcare needs.
QUESTION TWO
When a patient medication information is incorrectly entered into an Electronic Health
Record, it may lead to serious consequences such as medication overdose. Using the nursing
informatics skills framework, a midwives or nurse should apply technical, clinical,
information management and safety competencies to identify the error , correct it , report it
and prevent future occurrence. The steps in doing so are:
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IDENTIFY THE ERROR USING INFORMATION AND COMPUTER LITERACY
SKILLS : Recognize and verify the error in the Electronic Health Record system. Review the
patient medication record and compare it with physicians prescription, medication
administration record, patient history and current treatment plan. Confirm whether the
dosage, frequency or medication name was entered incorrectly. Assess the patient for any
signs of overdose or adverse drug reaction. This helps nurses to critically evaluate digital
information and detect inconsistencies, ensuring patient safety.
CORRECT THE RECORD USING INFORMATION MANAGEMENG SKILL: Follow
institutional policies for correcting electronic documentation. Edit or update the incorrect
medication entry without deleting the audit trail. Clearly document the corrected dosage
medication or administration details. Add a note explaining the correction and the reason for
the change. Proper correction maintain data accuracy, transparency and accountability within
the system.
REPORT THE INCIDENCE : That’s Professional and safety competence , inform the
supervising nurse in charge or physician. Document the incident using the hospital incident
reporting system. Complete an electronic incident report explaining what happen, when it
happen, Action taken to correct it and Monitor the patient closely for complication. Report .
PREVENTION OF SIMILAR ERRORS IN THE FUTURE: That is quality improvements
and information skills. Participate in root cause analysis of the incident. Recommend
improvement such as medication dosage alert.
Double – check verification system. Standardized medication entry templates and encourage
staff training on safe HER documentation. Promote regular review of medication records
before administration. This helps reduce future errors and improve overall patience safety.
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