Transcript What is the Paperless Chart?

Image from www.shockmd.com/wp-content/moblieand-station
JennaLedger






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


Computers are the new patient chart
“COW “ or computer on wheels, PDAs, and
laptops
(Plas, 2007)

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
THE SOFTWARE
•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

Laptop cart vs. PC cart

Patient Scanner

Storage areas

Work space

Sharps Container

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
• 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



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





Type of system: Special Purpose
Health Care professionals use EMR
Functions
Data standards used in this system
Disease and Procedure Classification System








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)






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)







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)
Computer Skills
1. Administration
2. Communication
3. Data Access
4. Documentation




Open Communication with team members
Training on RN Staff
Re-functioning of program to increase
documentation
Running pilot test before new functions go live

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-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