Computerized Charting Renee Lynn Objectives Describe 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 Describe the technology- related competencies of the professional nurse working with computerized charting l Describe the functions of the informatics nurse working with computer charting l l l l

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

Describe Hardware l l l 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

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

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

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

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

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

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

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

References l Capterra. (2009). Capterra the smart way to find software. Retrieved march 7 th 2009, from Electronic medical records software finder. Website: http: //www. capterra. com/electronic-medical-records-software. l Ergo Partners healthcare solutions. (2004). Retrieved march 8 th 2009, from the complete electronic medical record solution website: http: //www. ergopartners. com/module-clinicaldoc. asp. l Mc. Gonigle, D. , & Mastrian, K. (2009). Nursing information and the foundation of knowledge. Sudbury M. A: Jones and Bartlett. l Mulvihill, C. (1997). Advantages of computerized charting in college health. Retrieved march 5 th 2009, from advantages of computerized charting in college health website: http: //www. pitt. edu/~cjm/f 97 adv. html. l Thede, L, Q. (2003). Informatics and nursing: Opportunities and challenges. Lippincott Williams& Wilkins. Retrieved march 8 th 2009 from website: http: //books. google. com/books? id=t. JOUVats 7 d. AC. l Turpin, P, G. (03 -30 -05). Transitioning from paper to computerized documentation. Retrieved March 7 th 2009 from, Gastroenterology nursing, website: http: //www. sgna. org/Resources/article 3. pdf. l Shughart Thomson & Kilroy. (01 -01 -06). Media Center. Retrieved march 8 th 2009, from Legal issues and electronic medical record website: http: //www. stklaw. com/news/xpr. News. Detail. aspx? xp. ST=News. Detail&news=48.