Image from and-station JennaLedger

 Examine the paperless chart  Describe the software used in the paperless chart  Assess the effect of nurse’s work day  Assess the effect on patient care  Legal issues involving a paperless chart  Advantages and Disadvantages from a nursing perspective

 Computers are the new patient chart  “COW “ or computer on wheels, PDAs, and laptops (Plas, 2007)

 All patient information including: Progress notes Medications Laboratory results Radiology Images Tests and Procedure All orders (current and discontinued) Surgical procedure reports Assessments Recommendations Discharge Planning, etc.

THE HARDWARETHE SOFTWARE

Computer on Wheels Stationary PCs Laptops PDAs (Anderson, P, 2009)

Computer on Wheels Image from

 Laptop cart vs. PC cart  Patient Scanner  Storage areas  Work space  Sharps Container

 There are many options for software here are some examples:  AdvancedMD EHR Software  Allscripts  eClinicalWorks  athenaClinicals  GE Healthare: Centrity  Eclipsys  gMed  Altos Solutions: OncoEMR  Pulse Patient Relationship Management  SequelMed EMR  SOAPware Clinical Suite

Also known as electronic medical records (EMR) software Information usually found in a patient’s EMR is progress note aka SOAP notes, problems, medications, vital signs, past health history, immunizations, laboratory results and radiology reports. EMR can also be used to pull together a patient’s hospital bill Benefits of using EMR compared to a Paper Chart: data security reduction in documentation expenses shorter billing cycles Improved clinical decision making Better documentation

 AKA Sunrise Acute Care  Ranked #1 physician adoption satisfaction  Documentation available for Med/Surg, Telemetry, CCU, ICU, Labor and Delivery, Post-Partum, and Psych Patients

 Type of system: Special Purpose  Health Care professionals use EMR  Functions  Data standards used in this system  Disease and Procedure Classification System

 Overcome problems and delay when transferring paper medical records  To improve problems with loss or misplacement of physical records  No time needed for handling and/or filing  Increases the security and confidentiality  More efficient and effective consultations  Notes are legible  Enhanced quality of care  Faster and more efficient diagnosis and treatments ( Spring, 2008)

 Staff training  Lack of national protocol  Lack of institution protocol  Fear of change and the unknown  Data Security  Financial difficulties to upgrade to the EMR  Example : buying the software, upgrading computers (Spring, 2008)

 Privacy and co of EMR  Who should and could have access to patient records  Printing of data  Data Storage  Social networking Sites  Loss of computer  Use of proper waste of printed information  Example : HIPPA binds and shredding of files (Polack, 2008)

Computer Skills 1. Administration 2. Communication 3. Data Access 4. Documentation

 Open Communication with team members  Training on RN Staff  Re-functioning of program to increase documentation  Running pilot test before new functions go live

 Whether we like it or not EMR are the new chart of the future

References Rubbermaid Medical Marketing Case Study Norwalk Hospital: Norwalk, CT. Retrieved October 4, 2010, from CASESTUDIES/Documents/RubbermaidMedicalSolutions_NorwalkHospital Casestudy.pdf Anderson,P. (August 4, 2009) The Leading Peer-Reviewed eHealth Journal. Journal of Medical Internet Research. Retrieved on October 4, 2010, from Polack, Peter. (2008). More about Legal Issues with Electronic Records. Retrieved on November 20, 2010 from records.html. records.html Spring, Manda. (December 16, 2008) EMR Advantages and Disadvantages. Retrieved on November 17, 2010, from Staggers, Nancy. (2002). Results of a Delphi Study to Determine Informatics Competencies for Nurses at Four Levels of Practice. Retrieved on November 19, 2010 from Utah.edu/informatics/competencies.htm