The New Patient Chart:The Computer

Image from www.shockmd.com/wp-content/moblie-and-station JennaLedge

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Objectives

Examine the paperless chart Describe the software used in the

paperless chart Assess the effect of nurse’s work day Assess the effect on patient care Legal issues involving a paperless chart Advantages and Disadvantages from a

nursing perspective

What is the Paperless Chart?

Computers are the new patient chart

“COW “ or computer on wheels, PDAs, and laptops

(Plas, 2007)

What can be found in the computer chart?

All patient information including:•Progress notes• Medications• Laboratory results• Radiology Images• Tests and Procedure• All orders (current and discontinued)• Surgical procedure reports•Assessments• Recommendations• Discharge Planning, etc.

Image from alexfatoryillustration.com Image from www.dil316.com/images/CD.jpg

THE HARDWARE THE SOFTWARE

HARDWARE OPTIONS•Computer on Wheels

• Stationary PCs

•Laptops

•PDAs

(Anderson, P, 2009)

Computer on Wheels

Image from http://www.rubbermaidmedical.com/SOLUTIONS/CASESTUDIES/Documents/RubbermaidMedicalSolutions_NorwalkHospitalCaseStudy.pdf

Computer on Wheels Laptop cart vs. PC cart

Patient Scanner

Storage areas

Work space

Sharps Container

SOFTWARE OPTIONS

There are many options for software here are some examples: AdvancedMD EHR Software Allscripts eClinicalWorks athenaClinicals GE Healthare: Centrity Eclipsys gMed Altos Solutions: OncoEMR Pulse Patient Relationship Management SequelMed EMR SOAPware Clinical Suite

What is EMR Software?• Also known as electronic medical records (EMR) software•Information usually found in a patient’s EMR is progress note aka SOAP notes, problems, medications, vital signs, past health history, immunizations, laboratory results and radiology reports.•EMR can also be used to pull together a patient’s hospital bill•Benefits of using EMR compared to a Paper Chart:

• data security• reduction in documentation expenses• shorter billing cycles• Improved clinical decision making• Better documentation

ECLIPSYS: ACUTE CARE EMR

AKA Sunrise Acute Care Ranked #1 physician adoption

satisfaction Documentation available for Med/Surg,

Telemetry, CCU, ICU, Labor and Delivery, Post-Partum, and Psych Patients

Information System Review

Type of system: Special Purpose Health Care professionals use EMR Functions Data standards used in this system Disease and Procedure Classification

System

Advantages of EMR

Overcome problems and delay when transferring paper medical records

To improve problems with loss or misplacement of physical records

No time needed for handling and/or filing Increases the security and confidentiality More efficient and effective consultations Notes are legible Enhanced quality of care Faster and more efficient diagnosis and

treatments( Spring, 2008)

Disadvantages of EMR

Staff training Lack of national protocol Lack of institution protocol Fear of change and the unknown Data Security Financial difficulties to upgrade to the EMR

Example : buying the software, upgrading computers

(Spring, 2008)

Ethical and Legal Issues

Privacy and co of EMR Who should and could have access to

patient records Printing of data Data Storage Social networking Sites Loss of computer Use of proper waste of printed information

Example : HIPPA binds and shredding of files(Polack, 2008)

Informatics Competencies required by RN for EMR

Computer Skills1. Administration2. Communication3. Data Access4. Documentation

Functions & Responsibilities of the Informatics Nurse

Open Communication with team members

Training on RN Staff Re-functioning of program to increase

documentation Running pilot test before new functions

go live

Conculsion

Whether we like it or not EMR are the new chart of the future

References

Rubbermaid Medical Marketing Case Study Norwalk Hospital: Norwalk, CT. Retrieved October 4, 2010, from http://rubbermaidmedial.com/SOLUTIONS/CASESTUDIES/Documents/RubbermaidMedicalSolutions_NorwalkHospitalCasestudy.pdf

Anderson,P. (August 4, 2009) The Leading Peer-Reviewed eHealth Journal . Journal of Medical Internet Research. Retrieved on October 4, 2010, from http://www.ncbi.nim.nih.gov/pmc/artiles/PMC2762853.

Polack, Peter. (2008). More about Legal Issues with Electronic Records. Retrieved on November 20, 2010 from http://www.buzzle.com/articles/more-about-legal-issues-with-electronic-records.html.

Spring, Manda. (December 16, 2008) EMR Advantages and Disadvantages. Retrieved on November 17, 2010, from https://www.brighthub.com/health/technology/articles/7502.aspx.

Staggers, Nancy. (2002). Results of a Delphi Study to Determine Informatics Competencies for Nurses at Four Levels of Practice. Retrieved on November 19, 2010 from https://nursing. Utah.edu/informatics/competencies.htm