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Computerized Charting

Computerized Charting. Renee Lynn. Objectives. Describe Computerized Charting Describe Hardware List, describe, and evaluate software Describe and review the information system Describe Advantages and disadvantages Examine related ethical/legal issues

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Computerized Charting

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  1. Computerized Charting Renee Lynn

  2. Objectives • Describe Computerized Charting • Describe Hardware • List, describe, and evaluate software • Describe and review the information system • Describe Advantages and disadvantages • Examine related ethical/legal issues • Describe the technology- related competencies of the professional nurse working with computerized charting • Describe the functions of the informatics nurse working with computer charting

  3. Computerized Charting Description • Used to document patient care • Houses electronic medical records • Reliable accurate form of charting • Used in the U.S.A as early as the mid 1980’s. • Availability to current, relevant information software programs. Turpin (2005)

  4. Describe Hardware • The physical body of the computer and it’s components. • Central processing unit, motherboard, random access memory, hard disk, & power supply. • CPU is known as the “brain”. Speed is measured in gigahertz. • The more gigahertz the faster the computer runs. • Motherboard connects all components in some way. • Allows for the transfer of data. Mcgonigle and Mastrian

  5. Describe hardware • RAM is a temporary storage system. • Memory is lost once the computer is shut off. • Hard disk stores information that has been saved to the computer permanently. • Computers rely on a steady power supply. • The average power supply is 300-400 watts. McGonigle & Mastrian 2009

  6. List, describe, and evaluate software • EMRitus (Ergo Partners 2004) • Abraxas EMR • Medics Elite • Practice Partner Patient Records • Versa Suite Ergo Partners 2009 Capterra 2009

  7. Describe and review the information system • EMRitus software. • All care givers have access to up to date information. • All care givers “share information on a multi-disciplinary care plan.” • System comes with many “…ready to use templates.” Minimal keyboard entries. • Allows for “detailed and consistent documentation…” to be recorded “quickly and easily…” Ergo Partners 2004

  8. Describe advantages and disadvantages • All charts always legible. • Once proficient this method saves time. • No misspellings or repetitions. • Death rate from medical errors will decrease. (Shughart Thomson & Kilroy) Mulvihill 1997 Shughart Thomson & Kilroy 2006

  9. Examine related ethical/legal issues • Electronic Medical Records may compromise the patients privacy. • “Price – fixing” may occur because of access to payment information. • Medical malpractice insurance covers only personal encounters. Shughart Thomson & Kilroy 2006

  10. Describe the technology- related competencies of the professional nurse working with computerized charting • The nurse should have “basic computer and information management skills.” and be able to proficiently use… • Word processor. • Database. • Spreadsheet. • Decision support systems. • Become “fluent” in computers. Thede (2003)

  11. Describe the functions of the informatics nurse working with computer charting • Meets the information needs of current nurses. • Integrates and applies “information, computer, and nursing sciences.” Thedes (2003)

  12. References • Capterra. (2009). Capterra the smart way to find software. Retrieved march 7th 2009, from Electronic medical records software finder. Website: http://www.capterra.com/electronic-medical-records-software. • Ergo Partners healthcare solutions. (2004). Retrieved march 8th 2009, from the complete electronic medical record solution website: http://www.ergopartners.com/module-clinicaldoc.asp. • McGonigle, D.,& Mastrian, K. (2009). Nursing information and the foundation of knowledge. Sudbury M.A: Jones and Bartlett. • Mulvihill, C. (1997). Advantages of computerized charting in college health. Retrieved march 5th 2009, from advantages of computerized charting in college health website: http://www.pitt.edu/~cjm/f97adv.html. • Thede, L, Q. (2003). Informatics and nursing: Opportunities and challenges. Lippincott Williams& Wilkins. Retrieved march 8th 2009 from website: http://books.google.com/books?id=tJOUVats7dAC. • Turpin, P,G. (03-30-05). Transitioning from paper to computerized documentation. Retrieved March 7th 2009 from, Gastroenterology nursing, website: http://www.sgna.org/Resources/article3.pdf. • Shughart Thomson & Kilroy. (01-01-06). Media Center. Retrieved march 8th 2009, from Legal issues and electronic medical record website:http://www.stklaw.com/news/xprNewsDetail.aspx?xpST=NewsDetail&news=48.

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