Hi Madge, We are documenting on line with NUR. The only thing that does get documented real time (some of the time) is the Admission Assessment forms. The idea of documenting real time sounds good but is not practical when nurses are caring for more than one patient. Many of our nurses document vital signs and blood glucose results soon after they are taken so they are available when the doctor makes rounds. The remainder of their charting is done as soon as time allows usually after the all assigned patients are assessed and morning medications given. Our ICU is documenting on line they do miss their paper flowsheet as do some of the doctors, even though we do have the Iatrics Visual Flow sheet for them to use.
Patricia Johnson Nursing Information Systems New Milford Hospital 21 Elm Street New Milford, CT 06776 860-210-7457 CONFIDENTIALITY NOTICE: This e-mail transmission message, together with any other documents or attachments, is intended only for the use of the individual or entity to which it is addressed and may contain personal information that is subject to confidential privacy regulations such as the Health Insurance Portability and Accountability Act of 1996 (HIPAA). The authorized recipient of this information is STRICTLY PROHIBITED from disclosing this information to any other party unless required to do so by law or regulation and is required to destroy the information after its stated need has been fulfilled. If you are not the intended recipient, you are hereby notified that any disclosure, dissemination, saving, printing, copying, or action taken in reliance on the contents of these documents of this message or any attachment, is strictly prohibited. Please notify the original sender (only) immediately by telephone or by reply e-mail and delete this message along with any attachments, from your computer. Thank you. _____ From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of Mueller, Madge Sent: Tuesday, November 14, 2006 5:08 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.
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