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TRANSCRIPT
The New Patient Chart:The Computer
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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
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
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