Nursing in a computerised setting

KC CHICK · Oct 14, 2001

I wish we had computers where I work. Sometimes the cases go so fast I get a hand cramp. (Tonsils and BMT's!!) I also can't stand to see all the paper that goes out in the trash.

The caring of nursing will always be there, this is just a different tool to use in order to get our documenting and educating done. I don't see any difference in having a patient read a handwritten instruction as opposed to a computer printout......with the exception that the patient will probly be able to decifer the computer printout better than some people's handwriting.

Shuja · Oct 15, 2001

:rolleyes: i think you are absolutely correct but it still depends on time. i have seen that kind of setting where the patient load is too high and the nurses or doctors can't even write about the patient. it becomes a big mess later on. i think that there should be a golden hour with pay for nurses and doctors to catch up with the work that they have missed due to the patient load. but if we think about it in different way writing does have its +ive impacts that it is too quick. well it seeems to be a big issue here at the moment which we are trying to solve.

thanks for your response.

but what do you thing about the standardisation of the nursing language???????

:confused:

thankyou again.

standardisation of nursing language

KC CHICK · Oct 16, 2001

I think all medical language (i.e. jargon) should be universal throughout the world. It just makes sense, doesn't it?? What means one thing here should mean the same thing in your part of the world and vice-versa. :)

Shuja · Oct 17, 2001

:confused:

Thanx for the reply

You know I was surfing through research papers on the net yesterday. I found out that there were hundreds of people who have said that there is a need for the standardization of the nursing language.

This is a quote from the web. It was published about 90 years ago. I think that 90 years have passed and still the debate is there but no outcome.

http://www.nursingworld.org/ojin/tpc7/tpc7_3.htm

While attending a special meeting of the ICN in Paris, I was naturally at once struck by the fact that the

methods and the ways of regarding nursing problems were ... as foreign to the various delegations as

were the actual languages, and the thought occurred to me that ... sooner or later we must put ourselves

upon a common basis and work out what may be termed a "nursing esperanto" which would in the

course of time give us a universal nursing language (Hampton Robb 1909).

Well we hope that something will come up and this will be achieved soon.

How about computerized patient records?????????? what do you think about that? Everybody can access those records. What about the confidentaility and ethics? That does not make any sense there.

How do you feel about it?

Take care.

Try to avoid opening letters "which are suspecious". This threat is getting everywhere. Everybody is panicking? Hope that this will soon come to an end.

Shuja

rninformatics, DNP, RN · Oct 18, 2001

How about computerized patient records?????????? what do you think about that? Everybody can access those records. What about the confidentaility and ethics? That does not make any sense there.

How do you feel about it?

Shuja [/b]

Hi Shuja,

Institutions (acute care facilities, home health agencies, physicians practices, etc) that have an EMR (Electronic Medical Record), CPR (Computerized Patient Record), EPR (Electronic Patient Record) or EHR (Electronic Health Record) have access and security features in place that prevent unauthorized accessing of confidential patient records. That is those that have authorization to do so by the systems' administrators can access that information. An example might be the nurse taking care of you on that particular unit can access your record but not a nurse on another floor or not a doctor who is not associated with your care/case. The electronic medical record in many ways provides more security protections than the traditional paper record. The originally envisioned 1991 Institute of Medicine's vision of a computer-based patient record's Gold Standards have not been achieved across the board. The ideal is that your medical history including previous diagnostic test results, etc would be accessible to any healthcare facility or practiioner treating you in Chicago as well as in another city or country. Thereby giving your care providers the information they would need to make knowledgable decisions about the care prescribed- they would not be flying blind by not knowing your medical history and previous tx received, etc. This 'ideal' of a universal EMR has been hampered by multiple factors: lack of standardization related to data transmission, languages, federal, state and international regulations to name just a few barriers. Related to confidentiality of patient information that is in electronic form, our government here has inacted and is in the process of implementing mandates specifically the Health Insurance Portability and Accountability Act (HIPAA).

For additional information on EMR see:

http://informatics.nurses.nu

AND

http://www.medrecinst.com/

For additional information on HIPAA, pt confidentiality and security see:

http://www.hipaadvisory.com/

AND

http://www.netreach.net/~wmanning/privacy.htm

Shuja · Oct 23, 2001

:rolleyes: Dear

I do understand that the access is more restricted than paper records but how about responsibility of the nurse. I have read about a case I have no idea how relevant is this story, "where nurse took her daughter with her to work and child accessed the records. She phoned the patients house and informed the family about the disease. "

I have also seen in A & E settings receptions and non nursing staff is capable of accesing the information. Where is confidentiality addressed in these situations? I do understand that there is nothing that can be loop hole free but still these cases are on increase.

There arises another issue in your reply that is standardization of nursing language.

I have posted a quote in my earlier reply that it had happened in 1910. Till than no light have been

put in this subject. Now a days we are trying to overcome this problem but still it seems to be the hard task.I wonder why have there been no advances till this date.

These are some of the critical issues that we are discussing these days.

Thanks for you reply> I really appreciate it.

Thanx a million

Bye for now

Shuja.

Faieza Ali · Oct 25, 2001

Hi,

I am a second year nursing student studying at UNITEC in Mount Albert, Auckand, New Zealand.

Iam required to do an assignment for a computer course, and the topic I am keen to explore electronic medical record.

From being in my clinicals I have see times where health professionals from multidisiplinary teams who are finding over excessing patients notes. By having medical records on the computer patients records can be accessed by anyone at the same time.

LadyNASDAQ · Dec 28, 2001

Computerized charting is the downfall of Nursing. A couple of years ago I saw the most eye opening thing happen. I had to go to a deposition and evidently, I was the only one who could type.

The whole case cost so much money because the Nurses had missed areas that were on pop up screens, missed important things like aspiration and seizure precautions as well as placed respiratory rates in heart rate areas and put ridiculous numbers in pulse ox spaces. This was more than one Nurse.

Anyways, my thoughts were why was I called on this case and I asked this of the Attorey who questioned me. Iwas told that I had such perfect charting that it was used to compare with the others.

All want to say is that Nurses are not computer operators. Trust me, my co-workers that I had worked with are excellent workers. If the paper charting had continued there is no doubt in my mind that the case would have been dismissed.

DAB · Jan 9, 2002

I have nursed both with computers and on paper and personally, I prefer paper. The computer system was limited by the number of computers available and MD's, secretaries, social workers, etc. were forever on our already scarce supply of computers for the nurses. Yes, there were computers available in the rooms but I found a real confidentiality problem with those computers. I might be charting on the roommate and look over my shoulder to see the other patient's family looking to see what I was charting. I would explain that the information was personal for the other patient and the family would say something like, "Oh, I was just wondering what was wrong with them." Also many times while charting in the room the other patient would ask what information I was putting down. Even explanations of how the information was personal for the other patient was ignored.

I often found myself charting after I had reported off (if the nurses taking my people weren't late) and would stay from 1 hour to 2 and more if it had been a hectic shift and most were. Believe me when a 12 hour day is extended to 13 or 14 or more on a regular basis, it gets weary.

Paper charting doesn't require a keyboard, doesn't go down on a regular basis or surprise you by shutting off every other word, doesn't require waiting for everybody and their brother/sister to get off the computer, isn't delayed by someone surfing the net, and you can guard your charting. I personally vote for paper charting!

rninformatics, DNP, RN · Jan 10, 2002

Originally posted by DAB
I have nursed both with computers and on paper and personally, I prefer paper. The computer system was limited by the number of computers available and MD's, secretaries, social workers, etc. were forever on our already scarce supply of computers for the nurses.

Yes, there were computers available in the rooms but I found a real confidentiality problem with those computers. I might be charting on the roommate and look over my shoulder to see the other patient's family looking to see what I was charting. I would explain that the information was personal for the other patient and the family would say something like, "Oh, I was just wondering what was wrong with them." Also many times while charting in the room the other patient would ask what information I was putting down. Even explanations of how the information was personal for the other patient was ignored.

I often found myself charting after I had reported off (if the nurses taking my people weren't late) and would stay from 1 hour to 2 and more if it had been a hectic shift and most were. Believe me when a 12 hour day is extended to 13 or 14 or more on a regular basis, it gets weary.

Paper charting doesn't require a keyboard, doesn't go down on a regular basis or surprise you by shutting off every other word, doesn't require waiting for everybody and their brother/sister to get off the computer, isn't delayed by someone surfing the net, and you can guard your charting. I personally vote for paper charting!

Your reports of inadequate numbers of devices is not uncommon. I wonder if your institution had any staff nurses involved in the planning and implementation of the information system? An adequate device to staff ratio should have been addressed or the problem (once identified) should have been resolved by either increasing the number of devices or investigating why the ones in the pt rooms were not being fully utilized. Related to your concern about families peeking over your should while you are entering confidential patient data. You have every right to be concerned and are legally, professionally and ethically obligated to maintain patient confidentiality. With today's laptop screens it is not possible for someone to look over your should and view data on the screen. There are security screen protectors that can be placed over computer monitors to prevent someone from viewing data on the screen unless that person is actually sitting directly in front of the screen. Issues like these can be resolved with good follow up by the IS staff. Many clinicians report feeling uncomfortable charting in the patient's room. Cultural and practice issues such as this can be resolved so that both the clinician and the patient benefit from technology without the technology taking anything away from the pt/caregiver interaction.

Nurses have been staying late to enter traditional pen and paper documentation for years. Increased patient case loads, increased acuity of patients, inadequate staffing, codes or unexpected patient procedures, are just a few of the other variables related to why nurses stay over.

Paper charting is frequently illegible, redundant and contains inadequate information. The paper chart can only be accessed by one person at a time, can be inappropriately accessed (and allow breeches in patient confidentiality) far easier than its electronic counterpart. Paper records can be easily mutilated and damaged; require more storage space, staff and monies to maintain and retrieve than computer documentation.

The majority of the problems you speak of can be attributed to: little or no user involvement in the planning and implementation stages, insufficient training of staff in using the system, poor system functionality/response, inadequate number of devices or under utilization of available devices and poor IS support of the users. The above factors and not the computer documentation or the electronic record should be eliminated. Evidence-Based research and practice has proven that the effective use of information systems technologies can decrease medical errors improve patient care and clinical practice. Lets not throw out the baby with the bath water.

rninformatics, DNP, RN · Jan 10, 2002

Originally posted by Shuja
Dear
I do understand that the access is more restricted than paper records but how about responsibility of the nurse. I have read about a case I have no idea how relevant is this story, "where nurse took her daughter with her to work and child accessed the records. She phoned the patients house and informed the family about the disease. "

I have also seen in A & E settings receptions and non nursing staff is capable of accesing the information. Where is confidentiality addressed in these situations? I do understand that there is nothing that can be loop hole free but still these cases are on increase.

There arises another issue in your reply that is standardization of nursing language.
I have posted a quote in my earlier reply that it had happened in 1910. Till than no light have been
put in this subject. Now a days we are trying to overcome this problem but still it seems to be the hard task.I wonder why have there been no advances till this date.

These are some of the critical issues that we are discussing these days.

Thanks for you reply> I really appreciate it.
Thanx a million

Bye for now
Shuja.

Shuja

My previous referrence to "standards" related to data transmission standards. Do an Internet search and research HL7 standards in data transmission.

Related to your previous post about Standardized Nursing Languages the article you posted in fact was published in 1998 and not "90" years ago.

In fact here in the USA standardized nursing language in the form of NANDA, NIC and NOC are in use. Yes you are correct that the debate as to which is better and which one or ones to use still goes on.

Much work has been done to develop a nursing language that includes nursing diagnosis (NANDA), interventions (NIC, Saba, Omaha) and outcomes (NIC, Omaha). Referred to collectively as the Nursing Minimum Data Set.

All of the above nomenclatures have been recognized by the ANA for inclusion in a Unified Nursing Language System, all are in the process of being added to the National Library of Medicine's Unified Medical Language System but none were developed PRIMARILY for use in automated clinical information

systems, are considered complete, comprehensive or without inconsistencies.

In deciding which language an institution will utilize several factors have to be considered:

Results of the Needs Assessment for an ideal system, your nursing and data needs, the type of patient data you want to capture and manipulate, etc. Will the nomenclature provide the capability to store and retrieve data from a structured database? Will each term in the nomenclature have a unique identifier (used for coding) to allow for data exchange? Can the terms used in the clinical nomenclature be mapped to other nomenclatures such as IC9-CM?

The Omaha System is the oldest and has several characteristics of a good nursing nomenclature. Saba's home health taxonomy does contain a very comprehensive list of interventions.

It all depends on what your organization's data needs are and how far you want to go.

I am familiar with the use of all 3-NANDA/NIC/NOC. At a previous institution I was employed by, clinicians used NANDA terminology in the wording of Nursing Problems via free text entry into the clinical documentation system.

Upon redesigning the organization's nursing notes and care maps I utilized NIC and NOC terminology. The outcomes and interventions could also be linked to the diagnoses of the North American Nursing Diagnosis Association.

This linkage assisted with the computerization of our documentation and the development of our Electronic Medical Record. This nomenclature was chosen because of its ability to be linked to NANDA (concepts already familiar to our staff nurses), its completeness of both interventions and outcomes, my familiarity with one of its testing sites (the Mulcahy Outpatient Center at Loyola University) and the University of Iowa's previous informatics work.

Do a little more research and I am sure you will find more up to date information related to the on-going work in standardized nursing nomenclatures.