I have found this to be true also. Coming from an ED environment, where there is considerably less documentation than in an ICU, we constantly had folks staying after the end of their shift to finish their "stack 'o charts". At first (prior to Meditech) overtime was a real issue, then when they were told no more overtime for chart completion, we started experiencing missing charting, "hidden" charts, and the like. While this particular crew was leery about documenting on-line, going into it with a "you will only document something once, and it will be electronic" made things a lot easier. We really tried to not have folks writing things down on paper napkins, only to transcribe it later into the system. Strong nursing involvement in the build of the CDS screens and the flow of the system to enhance the charting is paramount. About three weeks after our go live, we had a downtime.......and those nurses never looked back after that. They were glad the paper was gone. Now....the trauma form....that was a little more hideous, but after about 4 months of working on it, we did come up with an electronic form that was able to be used bedside by a scribe (as usually the trauma nurse was too busy!!). After things settled down, the trauma nurse would take over from there on the charting (signing on as herself, of course).
Sheral Graham Senior Consultant Healthlink, a Division of IBM IBM Global Business Services cell: 541-680-3239 [EMAIL PROTECTED] "Davis Daniel - Southern Hills" <[EMAIL PROTECTED]> Sent by: [EMAIL PROTECTED] 11/20/2006 05:44 AM To "Mueller, Madge" <[EMAIL PROTECTED]>, <[email protected]> cc Subject RE: [MEDITECH-L] Real Time Documentation Madge, It has never been good practice for staff to work all day taking notes and then find a magically quiet time near the end of their shift to document everything that happened. But, with the paper chart we have felt that at least we could tell anyone who started looking at the chart that information not yet documented in it verbally. Of course, we still could have memory lapses and other issues could have impaired our ability to document so late. But, now in the computer world, anyone can be looking at the chart from anywhere in our facility, or even by dialing in from home. So, we no longer have that safety thing where we could see someone coming to read the chart and tell them what we haven’t entered in it yet. We expect staff to do something for the patient and then find a computer and document what they did. You will likely find that those staff who do that will not have overtime trying to document. Characteristically, those staff who save up all their documentation for the end of the shift are those who stay after their scheduled shift to get their documentation finished. Critical care units can be especially resistant to getting into the computer because it is nearly impossible to duplicate their tri-fold spreadsheets where the transcribe tons of information. But, with strong CNO support and a responsive PCM building efficient screens, you soon have CCU staff that would not want to go back to paper – for the most part. Daniel Davis, RN From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Mueller, Madge Sent: Tuesday, November 14, 2006 4:08 PM To: [email protected] Subject: [MEDITECH-L] Real Time Documentation Help! We are in the process of building our NUR documentation. We are wireless and have mobile computers and our expectation is that the staff will document in "real time". Our User Group feels we are being totally unrealistic and that there is no way nurses can document in "real time". They also feel that critical care units cannot document on line and should stay manual with a flowsheet. Are we being unrealistic? Are there any sites that actually have their staff documenting in "real time" and critical areas documenting on line? If so, what secrets do you have to get staff to accept? Thanks in advance for any assistance. Madge Madge Mueller RN, MSN Trihealth Information Systems Sr Applications Programmer/Analyst (513) 569-6814 [EMAIL PROTECTED] PRIVACY/CONFIDENTIALITY NOTICE REGARDING PROTECTED HEALTH INFORMATION This email (and accompanying documents) contains protected health information that is privileged, confidential and/or otherwise exempt from and protected from disclosure under applicable laws, including the Health Insurance Portability and Accountability Act. The information contained in this email (and any accompanying documents) is intended only for the personal and confidential use of the intended recipient. If the reader of this message is not the intended recipient or the employee or agent responsible for delivering it to the intended recipient, you are hereby notified that you have received this information in error and that any review, dissemination, distribution, copying or action taken in reliance on the contents of this communication is strictly prohibited. If you have received this communication in error, please destroy it immediately. ====================================== All messages should be posted in plain text. HTML will be converted to attachments. The meditech-l web site is MTUsers.com ______________________________________ meditech-l mailing list [email protected] http://mtusers.com/mailman/listinfo/meditech-l
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