School children are required to have a complete physical exam prior to starting school. The report is hand written by the physician and turned in by the parent to the school office. . During the school year, the child is only in contact with the school nurse if he/she is sick while in school or if he/she has an accident at school that requires medical intervention. If a child experiences problems after starting school and goes to see the physician, the school is not necessarily aware of what transpires during the visit. I see this as a potential breakdown in communication and a place where informatics could help. For instance, if the parents gave consent to the child’s doctor to release medical information to the school, then the doctor could have ongoing communication with the school nurse. I believe that if the information could be provided electronically, it would make it more convenient for the physician to share the information. Most health care providers are extremely busy and may not be willing to hand write information. With the use of electronics, the doctor could dictate the information for input by a medical assistant. The school nurse could then have easy access to that information. The school nurse could have a database for every child where this information could be stored. I think this information would be especially helpful in assessing/detecting problems associated with hearing. A child who is having difficulty hearing may be mistaken for a child who is having behavioral difficulties. The child may be placed in a special program without identifying the root of the problem. If the child’s complaints are properly identified, then the nurse could tailor her interventions accordingly. The nurse could also use this form of communication to inform the child’s physician of problems that may be initially identified at the school.
Archive for the ‘Computer Charting’ Category
I have two children who suffer from seasonal allergies. Their symptoms are similar, usually characterized by rhinitis and frequent sinus infections. These recurrent problems often lead to frequent trips to the doctor’s office. In the past, I’ve been asked by the doctor to keep a hand written account of their symptoms to take back to the office. I believe that if the information could be sent to the doctor electronically, it would be more convenient for the pt, and the doctor could share the information with other clinicians. The data could also be organized to look for any patterns between patients.
Completing a thorough head to toe assessment is a skill that takes practice and a broad knowledge base. No body system stands alone. Completing a quality assessment of one system may lead to clues about issues or problems in another system. Although head to toe exam is recommended, it is important for clinicians to develop methods that work for them. Patients may present with acute symptoms or complaints that do not allow time for a comprehensive exam. It is vital for the nurse to be able to discern what level of assessment is required for each individual. A patient who is in obvious distress will require a much focused assessment and relatively quick intervention. The type of assessment can also be affected by the health care setting. Nurses working in an outpatient setting may have more time to complete a comprehensive exam and history. Nurses working in hospitals may have multiple patients with various problems that require focused assessments for the sake of efficiency. Some may have a modified head to toe examination technique. Documenting assessment findings have been greatly facilitated in the facility for which I am employed. Each patient room is equipped with a computer to allow for immediate entry of assessment findings. All units have at least five to six, computers- on-wheels (COW) that can be taken from patient to patient if needed. It is interesting to observe the level of competence exhibited by nurses. Novice nurses tend to take copious notes on each system while more experience nurses can gather much information about his or her patients during the general survey. As assessment skills develop, nurses can gather information with minimal effort.
As the electronic health record (EHR) becomes increasingly utilized across the nation, a standardized language will need to be implemented and followed. This will improve more accurate billing, informed patient management, increased precision of documentation, and improve knowledge. Functioning without standards would be chaotic, out of control, and confusing to all individuals. Standardization proves to enhance any process. With the strategic organizational initiatives of many physician offices, clinics, medical centers, and hospitals to implement an automated electronic environment for documenting a patient’s health history, which then automate other processes, the need increases for the uniformity of a language. The downside of the uncontrolled terminology of medicine has been accentuated by the computer age, because without standard vocabulary the ability to acquire knowledge about healing professions through information technology is limited. Many clinical applications available today have restricted utility because they cannot understand each other. It seems with the urgency of healthcare facilities implementing EMRs, the development of a standard language is critical and needs to be on a fast track to develop solutions. Healthcare information system developers are not waiting for the standards bodies, in existence today, to make these determinations. These developers know that precise medical words are needed to analyze the information from automated medical records, which will improve quality and service in healthcare. Rather than use any existing clinical vocabulary standard, they are creating their own dictionaries or vocabulary sets. Although this represents a slight improvement over un-encoded or free text documentation, each vendor working in isolation, are creating a terminology which cannot be read or understood by other systems. This makes the potential of data exchange and comparing impossible. It is imperative that healthcare organizations, vendors, and government agencies work collaboratively to implement measures to effectively localize, update, and disseminate healthcare terminologies, mappings, and other terminology-related content currently issued by national and international standards bodies. A standardized language in healthcare is something of a monumental task, but one that needs dedicated professionals in establishing these standards. Although some standard languages exist, developed by various standards organizations, the need is paramount of unifying a standardized language. Controlled medical terminology is essential to maximize the true benefits of implementing a fully operational EMR. Additionally, if all physicians, nurses, patients, hospitals, clinics, payers, and government agencies would commit to the same healthcare language, the one who unquestionably benefits from this is the patient who can be any one of us.
The nurse’s role in patient education cannot be more important. From the time a patient is admitted until the time they are discharged, the nurse caring for each patient need to be teaching 24/7. Having a patient educator is a waste of money in my opinion. This is one of the roles of the nurse. He/she should be constantly teaching their patient. The nurses are the ones taking care of the patient and know exactly what each patient needs. When a situation or opportunity arises, nurses need to take full advantage of it. Computer documentation can help track what has been taught. We all know that the patients need to hear this information multiple times in order to fully comprehend it. Patients are discharged quickly from the hospitals these days. Nurses need to take patient education to the next level by evaluating their teaching. Just telling or showing a patient something isn’t enough. Have the patient return demonstrate or verbalize what they now understand. Patient education is an integral part of nursing care and one of the most important things we do for our patients.
This is one area where healthcare informatics can be of great help. Instead of nurses trying to remember what to assess and what to write down, the health electronic record will indicate what assessment needs to be done and documented. If the nursing and hospital administration wants skin assessment done, they can include it in the program. And they can set the computer program to indicate to the nurse when this assessment should be done. Thus, the nurse does not have to guess in most circumstances.
Another part of the medical electronic record is the use of cameras. Some camera systems are able to insert an image of the skin assessment directly into the electronic chart. This is a huge time saver for of all nurses. No more writing essays on what was seen on the patients skin.
October 18, 2010
Importance of Skin Assessment in Elderly and Child Abuse, comment
Skin assessment is a more valuable tool than we give it credit or time for. There are so many clues to a long list of health issues; from the varience in color, turgor, texture, temperature and thickness, to hair distribution, and condition of the nails. All of these variances from norm could be linked to some health issue. Issues like nutritional deficiency, allergy, local or systemic disease; such as melanoma or systemic lupus erythematosus; or they could be signs or the ‘remnants’ of abuse.
Unfortunately, I don’t think the nurse on the floor routinely gives skin assessment the time or attention needed to pick up on these clues. The most opportune time to find these signs would be on admission, during the initial assessment. What I see on the floor, is short staffing more often than not, trying to care for more patients than can be fully cared for during their shift, and bed shortages, requiring ’quick’ turnover. I am also afraid that the gains in my staffing numbers over the past year are in jeopardy with the reforms and cuts in reimbursement that I think are coming. Thorough assessments are an essential part of health care, of preventative medicine, and all of our professional practices; so I truly hope there will be the time and ability going forward to complete this valuable task.
May 26, 2009
Title: Importance of Skin Assessment in Elderly and Child Abuse
In studying skin assessment, one cannot help feeling overwhelmed. Without a desire to pursue dermatology, the unlimited amount of skin lesions, pustules, macules and papules can lead one to skim over information out of the pure necessity for mental sanity. The mind can only hold so many pictures at once. However, I do see the need to ensure the memorization and ability to recognize and diagnose normal skin variations. In reading articles and working with children and the elderly, one unfortunately sees the reality firsthand of physical abuse and neglect. This can often be recognized by assessing the skin. Breakdown, malnutrition, physical abuse, bruises, injuries at different stages of healing can all be noted by a thorogh assessment of the skin. As follow up care and the big picture should always be a part of our thought process in nursing assessment, the ability to note whether a skin assessment finding is simply normal or abnormal is vital to our practice.
The age of technology has made great strides in the medical profession, improving the care of patients and in many ways making bedside nursing more efficient. I began my nursing career in the mid 1970’s, everything was done on paper, the lab would come and draw blood at 6 o’clock in the morning to tell us what a person’s blood glucose was for insulin coverage prior to the bedside glucose monitors we now have. The younger nurses that I work with love to hear about the “old days when” from myself and other nurses who have been around for more than a decade.
As we go through our daily work week we have cat scan, x-ray, lab draw results continuously flowing through our computers, usually available within an hour of a patient being tested, allowing for further testing and treatment decisions that use to take up to 24 hours or longer for doctors to accomplish, are now accomplished during a single shift.
From Monday to Friday information flows smoothly most of the time, but then it is the weekend and it seems that time reverses and we are in another era. This past weekend was my weekend rotation, I recall one patient in particular that was hoping to go home, his discharge was going to be determined by the results of an echocardiogram that was done early Saturday morning. His cardiologist came in at 1 o’clock, no report was available within the computer or when cardiac testing was called. Sunday came and went, Monday morning the man was discharged.
This scenario was seen more frequently prior to the technology now available to us, however it needs to be available seven days a week to give the best care possible and save money, the weekends need to catch up technologically with the Monday through Friday work week.
I started my medical career as a Care Attendant, then a Licensed Practical Nurse, and finally a Registered Nurse. Over this time I have worked in two different states and seen many changes in the continuing evolution of the nursing profession.
The most recent changes have been primarily within the way we record our care. Over the past few years electronic charting has overtaken more and more aspects of our daily routines, not only do we record each patients vital signs within the electronic record, we record whatever they eat and drink, each use of the ladies and gentleman’s room, and most stressful for nurses, the exact times we medicate. We are given an hour, half our prior and half hour after the scheduled time of a medication to administer it. That doesn’t sound hard to do, but when staffing is short a nurse or a nurse assistant, more is expected to be done by each nurse on the floor. It is not always possible to adhere to this tight timeline, and all the time in the back of your mind you know that each day a printout is generated and sent to each nurse manager showing who was late with their medications, and each floor is sent a monthly record that is hung in the medication room showing each floor within the hospital and the percentage of times medications are administered on time, and when they are late.
We find that our computers on wheels are never more than a fingertip away, and the information that we put within the electronic record is growing with each passing day. It is an electronic strangle hold that has the floor nurse’s attention rather than the patient having the attention.
Healthcare informatics is utilized by most healthcare facilities and professionals in the United States. In the daily care of patients, some form of computerized technology is used. In studying skin, hair and nails, head, eyes, ears, nose and throat, and the respiratory system, different forms of technology are utilized to complete assessment of these body systems. In terms of an electronic medical record, the assessment of these body systems are imputed into a computerized program. This allows this assessment to be accessed by all healthcare providers caring for a particular patient. Vital sign assessment is completed by computerized technology such as an automatic blood pressure and temperature assessment. Computerized radiological equipment such as CT scanner is used to assess body systems including the head, nose, throat, lungs, etc. Also, computerized laboratory equipment is utilized to assess body systems such as blood gases for the respiratory system. With this explanation, it is apparent the overlap of healthcare informatics and health assessment.
I believe that point of care charting will end many of the current problems with the hand written medical record. Especially, difficulty in deciphering handwriting. Handwritten notes have historically been difficult to interpret and dependent on the writer’s penmanship, spelling, use of unaccepted or unknown abbreviations, or general use of the English language – all make for poor flow of care and communication. Inability to read/understand the notes written by staff that cared for the patient before I did leads to errors and exposes patients to risk for poor outcomes. As noted by others, point of care charting will end the longstanding problem of nurses writing on their hands, scribbling notes on scraps of paper hoping not to lose them before they find a minute to sit down and transcribe them onto a paper chart or mentally trying to remember minute details only to be overwhelmed while multi-taksing and totally forget to chart important information into the chart. We will be "going live" with computerized documentation in our unit in a few weeks. We have the luxury not being the first unit in the hospital to go live. So we have the benefits of learning from our peers and have been able to avoid, or so we think, some problems. We have had input in to the devices that will be installed into each cubicle as well as a voice into which COW (or WOW) is chosen for use in our busy area. We know it will not be the solution to all of our problems but it is, we think, a move in the right direction.
May 3, 2010
Title: Assignments and Point of Care Testing
Assessments and point of care charting Assessing the patients and directly inputting the information electronically can help with many things. Obtaining correct information, location, description, improving and worsening data can improve if we are able to input all the information at the patients bedside. I agree with the other writer about the COWS. I have never used one in a patients room. Working in Emergency, we often write things down on a piece of paper and use our memory for what is not jotted down. The only time it is fitting for us in Emergency to use a COW is during a Code where inputting the medications and procedures as they are being done saves a lot of time. If you simply write down each step on a piece of paper, then sit down to chart on the computer after it can take up to 20-30 minutes. Another idea instead of COWS or small hand held devices is to give each nurse her own laptop to use for the day and give it to the next shift as they come in. Lap tops are not too small or too big. Charting at the bedside for assessments and having the MAR on hand to check at bedside is helpful.
March 1, 2010
Title: Assessments and point of care charting
I absolutely agree with all the comments presented in the below link. Being that computerized documentation is less than 6 months old in our main facility, bedside point of care charting is a relatively new concept. It used to be that the only documentation performed at the bedside was the patient database and even then, most of that information was gathered on initial assessment and we would then go out to the desk to complete the paperwork. I think as more organizations embrace technology, more thought needs to go into the purchasing of equipment. At our facility, the managers for each unit were given a budget to purchase the style of computer they thought would be best suited for that particular unit. Pods were designed with central computers, handheld devices were purchased as well as COWs (computer on wheels). Many units after the fact discovered that the COWS were too big to get to the second bed in the room. This caused non-compliance with The Joint Commission standard stating that the e-mar must be at the bedside when administering medications. Other units found the hand held devices to small to use – the type to difficult to read. Pods are great for the primary nursing concept but takes the nurse away from the bedside. Many areas discovered just how few available outlets they had how short a battery life really is. We even had to become politically correct when a patient complained to administration that she overheard a nurse in the ER referring to "that stupid COW that had died in the hallway" – not realizing the nurse was frustrated that no one had bothered to plug the computer in to charge. We now refer to COWS as WOWS – work stations on wheels. With all that aside, we are finding that wall based point of care computers work best allowing optimal contact with the patient while gathering crucial information to be utilized in their treatment of care – as long as the computer is not on a wall that forces your back to the patient the entire time you are typing!
December 14, 2009
Title: Assessments and Point of Care Charting
Charting patient assessments is often a time consuming task, but vital to the care of the patient and record keeping. Nursing often jot notes down on a piece of paper, to only later record them into the computer system. Much may be lost in the translation. In addition, actions may be taken on the charting that in currently in the computer, though it may not always be the most current reflection of the patent’s status. Point of care systems have become paramount for charting in acute care settings, especially on critical care units. They often interface with medical devices to collect data automatically. These systems are often flowsheet orientated and provide graphing and trending capabilities. Optimally these systems create less redundancy, offer quick responses and interface with other clinical operations such as the laboratory and pharmacy departments. The computer availability is also an important consideration. Central computers have not always enhanced charting as they may take nurse from the bedside. Point of care charting should be convenient points of access to the system. Computers on Wheels (COWS) are found in many organizations. The portable, efficient system allows the nurse to chart in the patients room when appropriate. Bedside systems at the point of care focus on quickly capturing information that a nurse may otherwise jot down on their notes. Computer location should be given thoughtful consideration before investments are made in addition to the device’s speed and ease of use.
Tags: Healthcare Informatics, Healthcare Informatics Resources, Health Care Informatics Point of Care Charting, Health Care Informatics Computers on Wheels Charting, Health Care Informatics Assessments Charting, Health Care Informatics Work Station on Wheels, Health Care Informatics Assessment Computer