jbabineau

If you will consider/communicate to the monitoring person as a scribe for any/all documentation you would normally perform, I don't see the issue. Is it that a non RN is doing the actual assessment, or that they are putting that information in? MacLab automatically performs vitals and asks for LOC. MacLab also captures hemodynamic data and equipment data. The reports can be split so that nursing can get what is relevant-but there is so much more going on. For instance, is ACC/NCDR information being captured during the procedure? Does your system also control inventory/billing/standardized reporting? Is this information scrolled automatically to an IT system? Anything that you would normally document can be added at any time-communicate and educate non RN personnel as to what is needed in the chart (ie pain/intervention, procedure response, complications, comorbities that can affect the patient/etc). Hope this helps...

Our lab collects ACC/NCDR information during a procedure. We created out own workup template and coordinated our EMR to gather all relevant data in one place. I created quite a few custom forms (we use MacLab) in order to meet the needs of the physician (for the procedure note/standardized reporting), the hospital as a whole (pharmacy, units receiving patient), and HIMS. Our procedure record is checked for inventory/database/charge. Hope this helps...