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We went up with Phase I of the ED module in February, 2006.  We are
documenting the Triage and Discharge information on line.  On the whole
things have gone well and staff are adjusting.

Our team is now working on the main ED documentation.  The RN's and ERTechs
will be documenting.

The team is in a bit of a quandry.

Currently a  paper flowsheet that is a basic system review and a free flow
narrative form are used by the staff.
So right now the charting is pretty subjective.
Physicians will not be documenting at this time, they are doing Voice
Recognition Dictation.

Could some other facilities give me some ideas of how they are capturing the
visit information.
Are you using a flowsheet and then individual Treatment/Procedure CDS'?  Do
you hook the individual screens up with the Chief Complaint or are the users
required add them on.

We know that we want to capture charges with our documentation, and the plan
is to have queries on the CDS that will trigger the billing.

Any screen shots and/or other information sent our way is deeply
appreciated.

Thanks again for any input offered.

Trish Hahn, RN
Nursing Coordinator MIS
Little Company of Mary Hospital
Evergreen Park, IL 60805
(708)229-5196
[EMAIL PROTECTED]

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