Posts Tagged ‘Health Care Electronic Medical Record’

Electronic Communication, comment

July 23, 2013

Healthcare informatics Resources, May, 24, 2013, Electronic Communication [blog post],
My comment on electronic communications in the medical field is that this amazing tool often does not get the credit it deserves quite often because people that use these tools on a daily basis only think about how it makes their job easier, and true it does. However it does so much more than that. By reducing the amount of paper in the office it actually reduces the amount of accidents due to clerical errors, misdiagnosis, reduce the chance for under or overdosing of medications. And also increases the speed of information that travels that can mean a persons life in an emergency. There needs to be a study done on how (they’re probably already is one) many lives electronic records and systems save each year.

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Seasonal Allergies

April 22, 2013

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.

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Nurse charting in the hospital setting: Does electronic charting win? (comment)

November 29, 2010

We recently started electronic charting in the ED and it has been a challenge for all! One of the biggest pros in our ED are the decrease in patient complaints of never seeing a nurse or doctor. Our computers are stationary at each bedside so nurses are more visible and available for patients and families. It is so simple now to view patients charts without hunting down paper charts. Downtime is a problem but one that we are getting more accustom to.

Original Post
August 13, 2010
Title: Nurse charting in the hospital setting: Does electronic charting win?
Two years ago my hospital transitioned to electronic nurse charting. Adapting this new form of documentation caused a rumble amongst much of the staff. It seems there is always a natural fear that arises when something so new in form is implemented. At that time I had only been a nurse for a little over a year, so I was open to just about anything as I was not too set in my ways. I continue to hear the occasional comment reflecting back to the good ol’ days when charting involved nothing more than a pen and paper. Last week our computer system was out of service for three hours for upgrades and as I was charting, once again on paper, I began to contrast and compare the two different styles of documentation in my mind.

Electronic charting has many benefits. It’s legible, finite, organized, and consistent. For example, intake and output are entered and it automatically gives the nurses and doctors a net positive or negative daily fluid balance. With paper charting we had to painstakingly calculate intake and output hourly, which is basic math, but still remains time consuming. Patients’ lab values are automatically uploaded to their e-chart which also saves time. Vital signs automatically flow from the bedside monitor to the e-chart and simply need confirmation to be permanent. No longer are the days of placing triangles and dots for graphical depiction of vital signs.

There are some negatives to electronic charting. As stated above, down time for upgrades is always an annoyance. It causes inconsistencies in the patent record and is a hurdle for newer staff that never used our paper flowsheets. Some aspects are actually more time consuming than that of paper charting. Lags in servers and computer glitches often time cause sluggish operating systems. And of course there are always times when you have almost finished charting a long, detailed note, when the whole system crashes!

Grievances aside, I guess at the end of the day we all know that patient safety is the most important concern. With that said, I must admit that electronic charting is much safer than that of paper, therefore it wins my vote. As stated earlier, there is little room for misinterpretation. There is consistency among all staff, and patient records can be accessed by physicians anywhere in the hospital. Perhaps we are in the initial stages of developing a universal system that can be accessed by all institutions across the country. Wouldn’t that be nice!

Informatics in the care of thyroid cancer

August 9, 2010

I am a survivor of thyroid cancer – yeah, almost 8 years out!  Although I do not wish cancer on anyone, I can truly say that it has helped me as a nurse by truly understanding what the patient is going through.  I have been fortunate enough to be a patient at one of the world’s leading cancer hospitals for both research and cancer care and prevention. My journey with informatics at this hospital has been an interesting one of both healing and learning.  On my first visit in 2002, they were still using paper charts.  Pretty much no patient there sees just one physician.  I saw a head and neck surgeon and an endocrinologist and carried my chart from one appointment or study to the next.  Being the nurse-patient that I am, I felt compelled to take my chart into the restroom so I could snoop through it to make sure the doctors were telling me everything!  (They were.)  Shortly after that, they went to EMR.  I would go from one appointment to the next and they often would turn the computer screen towards me so I could see it too or print out the results of studies and reports for me.  That helped me feel informed and as if I were truly part of the care team.  Technologically, that place is awesome!  For a nurse, it’s truly an educational experience, not to mention the human examples of hope, courage and camaraderie experienced with other patients. From a thyroid cancer perspective, the technology involved lab (mainly TSH and free T4), ultrasound, PET scan after a drink of radioactive iodine and iodine ablation several weeks after surgery.  I now have graduated to the thyroid cancer survivorship program in endocrinology and also see doctors at the cancer prevention center for screenings and information in all areas of health.  I communicate with my physicians on the patient website, where I can ask questions, set up appointments, obtain knowledge and even participate in support programs to share with other patients.  On my appointment days,  I now spend the day visiting their libraries, shops, support programs or attending classes on alternative therapies such as yoga, music therapy, etc.   I receive news of the latest advances in care such as robotics, alternative therapies and stories of amazing healing.  With the advances in technology, this hospital has truly been able to offer a multi-disciplinary approach to care and healing that is accessible to both patients and care-givers alike.

Charting in the Era of EMR, comment

August 2, 2010

In the original post, the author speaks about the previous method of recording patient information, i.e. the paper trail. Unfortunately, even in present time, many health care facilities still use paper charting. As a nurse outside a large metropolitan area, I have found that within the city, most facilities use electronic charting; outside the city, many of us are still required to use paper charting. In this legalistic medical climate, there is always another form, another checklist, another documentation – and unfortunately, in the busy aspects of patient care, it is possible to omit something that may become an important piece of documentation in the future. This became very real recently in my new job as a case manager in a large mental health facility. A large amount of documentation, dating back 3 years was required for survey in an individual with a seizure disorder, mental retardation and mental illness. Two cumbersome (and intimidating) paper charts were brought to me to study and locate the proper documentation – an original consent signed by the guardian giving permission for the individual to take seizure medications and antipsychotics, among other documents. After spending hours looking for necessary documentation, there were still missing pieces to the puzzle. Seizure disorder is usually diagnosed with the aid of an EEG, a product of technology which confirms bursts of neuron activity in the brain; nowhere was an EEG found. Recording of seizure activity was not only difficult to follow, but most likely incomplete since it was relying on human elements such as neat handwriting, remembering to chart and placing documentation in the proper place in the chart. Most antipsychotics and seizure medications have risk of potent adverse effects – sedation, anticholinergic properties, extrapyramidial effects, neuroendocrine changes and weight gain to name a few. Consent is required in the long term care facility. How much easier it would have been to look on a well produced electronic chart for this documentation – which never was located! Within this health care facility, nurses deal with the illness of the human mind on a daily basis. The amazing human mind also created electronic charting – information retrieval systems capable of tracking healthcare in an orderly, legible and easily accessible format. It makes sense to use informatics to improve patient care, nurse productivity and the retrieval of patient information.

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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