Charting in the Era of e-mar, comment

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Part of my role as a nurse clinician is that of ensuring that a newly hired RN is able to independently pass medications. Our facility policy is to have the initial med pass performed with a clinician and once deemed competent the new hire can continue medication administration under the supervision of a nurse preceptor (another RN assigned to that nurse). Like most hospitals, the demand to push these new nurses through the orientation process and into independent practice is tremendous. We often short come the orientation and nurses today are learning on the fly. A proper preceptorship should consist of a seasoned and experienced RN with a smaller patient load, working with the new hire and delegating tasks until they feel the new nurse can perform and handle a patient load on their own. In the real world – the new hires are often treated as additional staff and the preceptor is ending up with double the patient assignment because they have an "extra" pair of hands. The preceptor is so busy trying to complete and care for the additional patients the new hire is often left unattended. During an observed medication pass this morning I was dismayed to watch the nurse flip to the drug information screen on her e-mar instead of actually taking the time to look up the medication in a drug guide. Was it more time effective? Yes, but she just glanced at the first sentence or two grabbed a keyword and assumed that was the drug’s intention. A few times I had to encourage her to go back and read the entire screen – point out that she was glossing over key information such as adverse reactions or drug interactions. With all the tremendous technological advancements we are making in healthcare today, I hope it is not as the cost of patient safety and nursing accountability.

Original Post
January 4, 2010
Title: Charting in the Era of EMR
I am still of the era of nurses that entered a patients room with my rounds sheet tucked into my uniform pocket.  The secret was to not let the patient see this sheet, and be able to remember their name, main diagnosis, and what you needed to check in them.  You would go through your complete assessment including vital signs, and when you left the room you would pull out your little sheet of paper and write down all of the information you just collected.  This procedure was repeated for all eight of your patients.  When you were done, you then sat at the nurses’ station and pulled the individual charts so you could transfer the information onto the required forms. 

It is not hard to see how the electronic medical record has benefited the role of nursing.  The first improvement is in time management.  You can actually take the information and enter it once.  This is the only time you write the information.  The second advantage is in correct data entry.  You can enter the data as you gather it.  There is less chance of forgetting the information before you write it in the patient record.   The third benefit is in gathering the correct information on each patient.  Electronic medical records prompt you to gather the required information.

I speak purely from a hypothetical standpoint because I personally have not had the chance to utilize an electronic medical records system.  Our hospital is still struggling to come up with the money required to purchase and implement a system.  I can, however, dream about how easy it will make my life once we get one!!!

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