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We default the WNL documentation into a box display on the screen, no F8
required. The documentation changes for each system, so we are able to have all
the systems on one page.
If the system is not WNL the N response triggers a popup for documentation.
When we upgraded to 5.5 in April we had to tweak the macros but they are all
working as designed.
(Thanks to Daniel Davis for the 5.4 macros for the documentation boxes &
popups.)
Jacqui Brindlinger
Mercy Medical Center
Canton OH 44708
[EMAIL PROTECTED]
-----Original Message-----
From: [EMAIL PROTECTED] on behalf of Kenny Whiteside
Sent: Fri 5/12/2006 1:14 PM
To: [EMAIL PROTECTED]; [email protected]; [EMAIL PROTECTED]
Cc:
Subject: RE: [MEDITECH-L] Charting by exception (Using Standards)
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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 >>>
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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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