The wonders of electronic documentation

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The Electronic Health Record (EHR) is here to stay. I noticed in several of the posts that there is a generalization of how easy it is to use and how great it is going to be. Be careful with this, because there is still a human component involved with EHR. And humans hate change. I currently work in a small community hospital that is in the middle of activating EHR and we seem to be doing it backwards. As a Nurse Clinician and Analyst for the EHR system, there a many bugs that need to be worked out. Which part of our current system interfaces with the new system? What new systems needed to be purchased to enhance the system we are trying to implement? The building of the EHR system is in its third year, and we certainly are having our ups and downs. What to add, where to add this assessment, where to add this reassessment? It can be very daunting and confusing, to say the least. Even for someone familiar with the system. Unfortunately EHR is not a cure-all, and hospitals attempting to introduce EHR into its system need to listen to what other facilities are doing right and doing wrong. There are definitely lots of both. Good luck with EHR.

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One Response to “The wonders of electronic documentation”

  1. Admin Says:

    Two and a half years ago, I had my first, of very, very many classes in the introduction of the electronic medical records. Being a clinical educator, I was extremely excited for a revolutionary change that was about to come about in my organization. I tried to encourage my staff-at two campuses that it was a wonderful thing and it is going to prove to be easier and safer for our patients than what we were doing. I went to classes in sunrise clinical management, patient profile, EC-101, E-mar, and I cannot remember what else. It all seemed like a blur, but the “leaders” in these groups assured us, “it will all come together.” Now, at this present date, with the implementation of all these classes for the organization, we find that our Surgery department’s, PACU’s, Ambulatory units, the type of online documentation that was chosen, does not interface with all the rest. This is a dilemma. The gurus of the above listed online documentation and the gurus of SIS(surgical information system), do not know what to do or know how to proceed. Should all of peri-operative services continue to document our few medications that we give to our patients in the SIS program- or should they learn E-mar(the pharmacy driven online documentation). There have been conversations among our managers that we should stay within the confines of our SIS. The leaders of online documentation have said, we do not care, but someone has to make a decision-by Nov 8th. That is when E-mar-the pharmacy driven portion is going to go live. The leaders say that the ambulatory campus will not have to go on E-mar, as the patients are in and out in less than a day. There is always the problem of our members of our staff that sometimes float over to the in-patient campus. Being an educator, I see both sides, but someone has to make a decision soon. The education of the pharmacy portion is somewhat involved and our staff is having their difficulties with SIS. I have gone online and asked the question to my fellow nurses who might be in the same predicament as us. I think that when the entire process began over two years ago, someone might have had some kind of knowledge of the systems they were purchasing, upgrades we are going thorough, and whether every system talks to each other. Am I confused- but I do not think as confused as the leaders that have gotten us in this mess with not a clue on how to proceed. What I thought was once exciting, now has turned into a huge nightmare for the other educator and myself.

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