Some things can be done real time, and others that is an unrealistic expectation. Once the usual hustle of starting shift - assessments, doc rounds and meds are "done" for the moment, people can start charting and will use the "retro" feature to get things entered with the time they said they did them. Once caught up, many people will chart real time for smaller things as they do them, turns and ADLs, meds, re-assessments, etc if the device is handy (bedside units or some form of portable). Others will never be able to make this mental transition. Those that have transitioned seem to like it. We have the luxury of bedside clinical tunnel units in most of the rooms at both our facilities now, as there were significant issues with wireless reliability and security of devices at our places (we also have BMV).
-----Original Message----- From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] Behalf Of [EMAIL PROTECTED] Sent: Monday, November 20, 2006 5:09 AM To: Mueller, Madge; [email protected] Subject: Re: [MEDITECH-L] Real Time Documentation Hi Madge. I will be interested in seeing othe responses to your question. I think real time documentation can work in some areas; for example, ambulatory surgery, where the workflow may be such that the nurse is focusing on one patient at a time, and doesn't see another patient until the first one has been fully processed.. Real-time documentation would be a real challenge, however, on the in-patient side, where nurses may be carring for 5-6 patients simultaneously. Nurses in those practice settings have always done the bulk of their documentation during "down time". In any nursing unit I've seen, these periods of lower activity are pretty predictable. For example, once all the docs have made rounds, and lunch is over and the patients have been toileted, there is often a break in the usual frantic pace of the unit. This is when nurses can sit down and chart without being interrupted continuously by the needs of the patients. If the in-patient nurse were to document in real time, his first patient would receive his services in a timely fashion. But with each subsequent patient, those at the end of the line would have to wait longer and longer to see him. I could easily imagine pain and nausea meds being significantly delayed. The only real time documentation system that I believe would truly work would be some kind of voice recognition system that would allow the nurse to dictate in real time and make corrections/additions later. Lots of ICUs are online, and their flowsheet info can be online. It may not be exactly like their paper flowsheet, but they just have to make the mental transition from seeing the data in one format to another. Good luck! Sharon (ICU Director) -------------- Original message -------------- From: "Mueller, Madge" <[EMAIL PROTECTED]> 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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