non-licensed entering wound doc to software program?

noc4senuf · Mar 20, 2008

Why would you have a volunteer having access to your software program or that section of it? How is it to be explained to a surveyor that a volunteer was documenting on a wound? Another issue would be the dignity aspect. That would be something that no one except staff should have knowledge of... maybe a HIPPA issue also.

CraigB-RN, MSN, RN · Mar 20, 2008

As long as they have signed the appropriate HIPAA documents, no problem, no big deal. Why is it any different than the transpcriptionist? No legal problems at all. You treat volunteers just like employees in that sense.

I guess my question is why are you doing this in the first place. Is the data comming from the MD's notes and just being input into the computer or what? It's an effecency vs accuracy question of me.

nurse1717 · Mar 21, 2008

hi CraigB-RN, thanks for your reply. We have a new wound software program and don't have a laptop to carry around with us during rounds. notes are written down describing the wound then entered into the computer--the software program tracks patients. dates, wound (locations, size, etc.), treatments, etc. and can generate graphs, etc.

As in nursing, when one documents, one signs and initials.

Transcription from dication is different. The transcription is from voice to paper. The MD puts on tape (usually) their "notes" to be then transcribed to just that--notes on paper. The MD then reads the final draft and signs it.

Computer entry of wound documentation is the other way around. Notes on paper to computer. Thus my reason for asking about it's "legitimacy"-as it (the wound documentation notes) cannot be "signed and initialed" by the RN or CWS-unless there was a statement to that effect, ie, initialing below will serve as your signature...

thanks.

CraigB-RN, MSN, RN · Mar 21, 2008

It's not legitimicay, it's accuracy. And what the provider is going to use the documentation for. I'd suggest that some form of oversight. I'd hazard to guess that your docs don't read eaach detail of their dictation.

There is nothing wrong with a non licensed person,payed or volunteer entering data, what could be at fualt is your organizations policy on how the whole process is handled.