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We use a modified version that does state the normal.
If the standard is met, the nurse answers yes and skips the remaining
portion of the screen. If the WNL standard is not met, the nurse
enters the abnormals.
For example:
Respiratory Lungs CTA, breathing nonlabored, air moves freely with
Standard: symmetrical chest expansion. No Shortness of Breath.
Does not require O2.
Oxygen: Effort:
SOB: Pattern:
Excursion:
Lobes: Depth:
Sounds:
Lobes: Comment:
Sounds:
-----Original Message-----
From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED]
On Behalf Of Brian Golden
Sent: Thursday, May 11, 2006 3:21 PM
To: Debbie Lajoie; [email protected]
Subject: RE: [MEDITECH-L] Charting by exception (Using Standards)
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Deb,
I would suggest being careful with "charting by exception". It leaves
the fields blank if not answered. You can't distinguish whether a blank
means not applicable or they just didn't do it. Then, when someone asks
how long the patient had... or how many patients had this response, you
can't use the computer to do what it does best.
There are ways to deal with it. For example, if the question "WNL" is
responded to with a "Y", then use attributes to default in "N" to all of
the other questions.
Just think ahead for what information someone might ask you for later.
Brian
-----Original Message-----
From: [EMAIL PROTECTED]
[mailto:[EMAIL PROTECTED] On Behalf Of Debbie Lajoie
Sent: Wednesday, May 10, 2006 9:10 AM
To: [email protected]
Subject: [MEDITECH-L] Charting by exception (Using Standards)
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I am in the process of redesigning our Nursing Documentation System. We
are a Magic site utilizing the NUR module since the early 90's. We
currently use CDS's with attributes. Our plan is to move towards
charting by exception based on standards. Does anyone currently
document by exception and if so, what references did you utilize to
define standards for the documentation? Any assistance will be greatly
appreciated.
Thanks!
Deb
Debbie Lajoie RN
Information Systems
Application Analyst
Holyoke Medical Center
Phone #: (413) 534-2841
Pager: 755-8448
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