An electronic health record (EHR) integrates a patient’s multiple electronic medical records, physician-generated and patient-generated personal health records. It has been widely adopted in healthcare organizations since it helps providers and facilities have all the information they need at the point of care (Baus et al., 2018). In addition, the EHR has been associated with multiple benefits, including reducing medical errors and redundant paperwork and supporting physicians’ reimbursement. The purpose of this paper is to discuss an opportunity for care improvement and how the EHR can be used to track the improvement.
Patient falls are a common patient safety concern in the inpatient unit. They are related to adverse events that worsen patient outcomes, prolong hospitalization, and reduce patient satisfaction with care. The hospital’s fall rate in the past year was 6.3 per 1,000 patient days, and about 40% of these falls resulted in significant injuries. According to Moskowitz et al. (2020), the EHR can be used to assess patients’ risk for falls and identify those at high risk of falls, guiding appropriate fall-preventive measures. An EHR Fall-risk assessment tool will be ideal in helping providers assess and identify patients at risk of falls in the inpatient units and thus take measures to mitigate falls.
Key information required in the EHR database to track patients’ risk for falls includes a patient’s age, gender, and disease conditions or physical dysfunctions associated with a high risk of falls, like, gait and balance difficulties, muscle weakness, poor vision, and postural hypotension. In addition, chronic diseases associated with falls will be included in the database, like stroke, osteoporosis, cognitive impairment, dementia, and epilepsy (Ye et al., 2020). Moreover, a patient’s current medications will be needed in the EHR database, especially those used to treat diabetes, mental disorders, cardiovascular conditions, and NSAIDs, since they are established to have a strong relationship with increased fall risk.
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