The New Patient Chart The Computer Image from

The New Patient Chart: The Computer Image from www. shockmd. com/wp-content/moblie-and -station Jenna. Ledger

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.

THE HARDWARE Image from alexfatoryillustration. com THE SOFTWARE Image from www. dil 316. com/images/CD. jpg

HARDWARE OPTIONS • Computer on Wheels • Stationary PCs • Laptops • PDAs (Anderson, P, 2009)

Computer on Wheels Image from http: //www. rubbermaidmedical. com/SOLUTIONS/CASESTUDIES/Documents/Rubbermaid. Medical. Solutions_Norwalk. Hospital. Case. Study. 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: � � � Advanced. MD EHR Software Allscripts e. Clinical. Works athena. Clinicals GE Healthare: Centrity Eclipsys g. Med Altos Solutions: Onco. EMR Pulse Patient Relationship Management Sequel. Med 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/Rubbermaid. Medical. Solutions_Norwalk. Hospital Casestudy. pdf Anderson, P. (August 4, 2009) The Leading Peer-Reviewed e. Health Journal of Medical Internet Research. Retrieved on October 4, 2010, from http: // www. ncbi. nim. nih. gov/pmc/artiles/PMC 2762853. 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-electronicrecords. 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