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Hey Deb and Brian, Here's a different perspective: We use "Charting by Exception" and actually encourage our users NOT to enter normal values. For example, our nursing physical assessment is broken into systems. Each system asks "WNL?". They may Shift+F8 to see documentation as to what our definition of "Normal" is. If they choose "Y" to WNL's, they skip to the next system. If "N", they should only enter abnormal values. We then have a Mixed Query Group in PCI for Systems Assessment. Each system is built as a Query Group. The physician can choose "Cardiac" and see "N" to WNL and easily see what is abnormal without having to filter through the normal responses. Both our nurses and our physicians (OK... the ones that actually do use PCI) have been very satisfied with this approach. I'm not saying that this approach is any better, just thought I would share! Six inches is still half a foot! Thanks, Kenny Whiteside >>> "Brian Golden" <[EMAIL PROTECTED]> 05/11/2006 4:21:11 PM >>> All messages should be posted in plain text. HTML will be converted to attachments. The meditech-l web site is MTUsers.com ====================================== 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) All messages should be posted in plain text. HTML will be converted to attachments. The meditech-l web site is MTUsers.com ====================================== 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 [EMAIL PROTECTED] CONFIDENTIALITY NOTICE: This email communication and any attachments may contain confidential and privileged information for the use of the designated recipients named above. If you are not the intended recipient, you are hereby notified that you have received this communication in error and that any review, disclosure, dissemination, distribution or copying of it or its contents is prohibited. If you have received this communication in error, please reply to the sender immediately or by telephone at (413)534-2500 and destroy all copies of this communication and any attachments. For further information regarding Holyoke Medical Center's privacy policy, Please visit our Internet web site at http://www.holyokehealth.com <<<<GWAVAsig>>>> _______________________________________________ meditech-l mailing list [email protected] http://mtusers.com/mailman/listinfo/meditech-l _______________________________________________ meditech-l mailing list [email protected] http://mtusers.com/mailman/listinfo/meditech-l _______________________________________________ meditech-l mailing list [email protected] http://mtusers.com/mailman/listinfo/meditech-l
