Medical Records

[sls73]

We are looking at starting to go electronic with charting documentation. We currently use a computerized medication pass and charting for the nursing assistants(caretracker). What we are looking at is taking some of our already created forms ie- fall assessments, communication tools, skin assessments, and incident reports and putting them into the computer. We would still keep nurses notes/labs/xrays/and progress notes in a chart.

Has anyone started the process of going electronic and if so can you share with me some tips on how you got it started?

Please and Thank-you,

[oznerol1005RN]

hi everyone i'm new here.. does anybody know the present OIC/heads of PHC, EAMC, NKTI, MMC, LCP, and MC? thnx..

[HiHoCherry-O]

To the OP:

You may want to shop around for some EMRs. What kind of program are you using for your med documentation? Is it a software program that allows for other applications to be added such as the ones you listed?

The hospital I work for uses Epic. For the most part it suits our needs on a clinical level but I have heard the billing department complain about it not being user friendly.

If you have an in-house IT department, they may be able to build a program/application that is specific for your needs (also keeping in mind security issues). However, this in the long run can be quite expensive since it will be unlikely to integrate with any outside software that may be purchased in the future.

[Scarlette Wings]

our hospital uses a system called meditech. it is the only emar (electonic medical administration record) that i have had experience with. i used paper charting until i moved here so i wasn't present when they changed to computerized charting. it was a big change for me and i had almost no computer skills when i began.... so if i can learn it anyone can.

i was present for when they converted the medicine administration system onto the pc. you have to scan the patients id band as well as the medications and they all register in the electronic chart. it does seem to be the way of the future and is where healthcare (and all other fields actually) is heading. like it or not computers are here to stay and that will change everything for everyone.

it has been difficult to learn but the supervisors and it people are all very wonderful and patient and willing to teach. it does slow you down considerably when you are first learning to use the electronic system and seems like a necessary evil...like nurses need one more thing to distract them and slow them down. it is hardest for those of us without any computer background and older and set in our ways.

the best way to do it is to volenteer to learn and take on site classes about your individual system and how to use whatever styles your facility is looking at and become what they call a "superuser". then you can learn all the ins and outs and help others. it will be a bumpy ride but you will get there.

[CathyLew]

to the OP... is this a requirement for your hospital for Meaningful use? Not sure if you are acute, LTC or CAH. and do you intend to keep the current software you have for meds? if that is the case, what you look at has to interface with what you have. And you seem like you are looking at just a few things to make into your EMR right now... but do you down the road have to have everything electronic? that is one thing to take into consideration. Don't just look at something that will put paper forms into electronic forms at this point, and if to make Meaningful use, you have to get the whole med record electronic... you don't want to end up with a system of several things trying to interface. (each interface costs money)

I would suggest have your IT dept start calling vendors for demos.

[gentlegiver, ASN, LPN, RN]

I've worked at a couple place where they used a system called "PCC" (not to be confused with Point Click Care). It was very encompassing, and user friendly for staff. I would suggest you look into it.