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The New Patient Chart: The Computer. Image from www.shockmd.com/wp-content/moblie-and-station. JennaLedger. Objectives. Examine the paperless chart Describe the software used in the paperless chart Assess the effect of nurse’s work day Assess the effect on patient care
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The New Patient Chart:The Computer Image from www.shockmd.com/wp-content/moblie-and-station JennaLedger
Objectives • Examine the paperless chart • Describe the software used in the paperless chart • Assess the effect of nurse’s work day • Assess the effect on patient care • Legal issues involving a paperless chart • Advantages and Disadvantages from a nursing perspective
What is the Paperless Chart? • Computers are the new patient chart • “COW “ or computer on wheels, PDAs, and laptops (Plas, 2007)
What can be found in the computer chart? • All patient information including: •Progress notes • Medications • Laboratory results • Radiology Images • Tests and Procedure • All orders (current and discontinued) • Surgical procedure reports •Assessments • Recommendations • Discharge Planning, etc.
Image from alexfatoryillustration.com Image from www.dil316.com/images/CD.jpg The Hardware The SOFTWARE
Hardware options •Computer on Wheels • Stationary PCs •Laptops •PDAs (Anderson, P, 2009)
Computer on Wheels Image from http://www.rubbermaidmedical.com/SOLUTIONS/CASESTUDIES/Documents/RubbermaidMedicalSolutions_NorwalkHospitalCaseStudy.pdf
Computer on Wheels • Laptop cart vs. PC cart • Patient Scanner • Storage areas • Work space • Sharps Container
SOFTWARE OPTIONS • There are many options for software here are some examples: • AdvancedMD EHR Software • Allscripts • eClinicalWorks • athenaClinicals • GE Healthare: Centrity • Eclipsys • gMed • Altos Solutions: OncoEMR • Pulse Patient Relationship Management • SequelMed EMR • SOAPware Clinical Suite
What is EMR Software? • Also known as electronic medical records (EMR) software •Information usually found in a patient’s EMR is progress note aka SOAP notes, problems, medications, vital signs, past health history, immunizations, laboratory results and radiology reports. •EMR can also be used to pull together a patient’s hospital bill •Benefits of using EMR compared to a Paper Chart: • data security • reduction in documentation expenses • shorter billing cycles • Improved clinical decision making • Better documentation
ECLIPSYS: ACUTE CARE EMR • AKA Sunrise Acute Care • Ranked #1 physician adoption satisfaction • Documentation available for Med/Surg, Telemetry, CCU, ICU, Labor and Delivery, Post-Partum, and Psych Patients
Information System Review • Type of system: Special Purpose • Health Care professionals use EMR • Functions • Data standards used in this system • Disease and Procedure Classification System
Advantages of EMR • Overcome problems and delay when transferring paper medical records • To improve problems with loss or misplacement of physical records • No time needed for handling and/or filing • Increases the security and confidentiality • More efficient and effective consultations • Notes are legible • Enhanced quality of care • Faster and more efficient diagnosis and treatments ( Spring, 2008)
Disadvantages of EMR • Staff training • Lack of national protocol • Lack of institution protocol • Fear of change and the unknown • Data Security • Financial difficulties to upgrade to the EMR • Example : buying the software, upgrading computers (Spring, 2008)
Ethical and Legal Issues • Privacy and co of EMR • Who should and could have access to patient records • Printing of data • Data Storage • Social networking Sites • Loss of computer • Use of proper waste of printed information • Example : HIPPA binds and shredding of files (Polack, 2008)
Informatics Competencies required by RN for EMR Computer Skills 1. Administration 2. Communication 3. Data Access 4. Documentation
Functions & Responsibilities of the Informatics Nurse • Open Communication with team members • Training on RN Staff • Re-functioning of program to increase documentation • Running pilot test before new functions go live
Conculsion • Whether we like it or not EMR are the new chart of the future
References Rubbermaid Medical Marketing Case Study Norwalk Hospital: Norwalk, CT. Retrieved October 4, 2010, from http://rubbermaidmedial.com/SOLUTIONS/ CASESTUDIES/Documents/RubbermaidMedicalSolutions_NorwalkHospital Casestudy.pdf Anderson,P. (August 4, 2009) The Leading Peer-Reviewed eHealth Journal . Journal of Medical Internet Research. Retrieved on October 4, 2010, from http:// www.ncbi.nim.nih.gov/pmc/artiles/PMC2762853. Polack, Peter. (2008). More about Legal Issues with Electronic Records. Retrieved on November 20, 2010 from http://www.buzzle.com/articles/more-about-legal-issues-with-electronic-records.html. Spring, Manda. (December 16, 2008) EMR Advantages and Disadvantages. Retrieved on November 17, 2010, from https://www.brighthub.com/health/technology/articles/7502.aspx. Staggers, Nancy. (2002). Results of a Delphi Study to Determine Informatics Competencies for Nurses at Four Levels of Practice. Retrieved on November 19, 2010 from https://nursing. Utah.edu/informatics/competencies.htm