Latest Comments by DebCGH

DebCGH 414 Views

Joined: Apr 29, '09; Posts: 1 (0% Liked)

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    We have recently implemented T-system template documentation for our ER physicians. The physicians had been used to a joint form which blurred the lines of who should do what type of documentation: RN or MD. Some RN charting was seen as medical screening partially leading to the decision to go to T-system. After 4 weeks of using the system, the physicians want the nurses to complete the reason for visit and past medical history portion. They feel that since nursing already asks these questions, the physicians should not have to duplicate this information. Secondly, per T system recommendation, the physicians pull their own templates. As one physician just said, When I come in at 2am, it would be nice to have that sheet ready for me to fill out.

    My question to you:
    If you use T system at your facility, who pulls the templates for the MD. Does the nurse complete any documentation on the physician template?

    If you don't use T system, on your system, is the nurse doing any documentation on the physician form? If so, is this area easily identified as a nursing area or is it blended?

    Lastly, I work in clinical informatics -- I am an RN -- and was pulled into this project as the nursing area will eventually be charting electronically. So my knowledge base of ER physician documentation regs/rules is very limited. Can someone suggest where I can get good information on what they should be charting?



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