Healthcare has evolved in so many ways. One of the biggest changes has to do with charting. Nurses, physicians, social workers, etc. all have to chart, whether it is on paper or an electronic medical record (EMR).
Hospital organizations have been changing their paper forms of charting over to an EMR system. This can be a very daunting task for an organization to take on. Some items to be considered are as follows. The timeline of the form to EMR, different challenges to the conversion of the paper form, what mandatory components will be a part of the EMR, and how to make the EMR user friendly. Here is an example of changing over an emergency department admission record to an EMR.
The emergency department admission record form would take around twelve to sixteen weeks to implement (Electronic Medical Records Implementation).
When selecting a vendor, an organization must keep in mind that the vendor needs to have the organizations mission and vision implemented into the system. The reason for the time it takes to change over the emergency department admission record form to an EMR is due to building interface, ordering hardware, analyzing practice patterns and building training plans (Electronic Medical Records Implementation).
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Another way of changing the emergency department admission record over to an EMR is to scan the form using a program that can change it into a writable document on the computer. Saving this form to a shared network would allow users across the organization to access it and save the information that is gathered during the assessment.
There are many challenges of converting the emergency department admission record form over to an EMR system. One issue is that the emergency department admission form consists of a detailed list of items that help the nurses and physicians take care of patients. This information would all need to be changed over to the new EMR system. The form focuses on the patients name, allergies, date of birth, what their chief complaint is, their means of arrival, what their first set of vitals are, immunization history, mental health history, past medical and surgical history, pain scale, and their fall assessment score totals.
All of this information would need to be implemented into the new EMR form. Another challenge would be to make sure that this EMR system would be able to communicate with the other systems in the hospital. According to Hebda T. and Czar P. (2013) an interface engine software would need to be created, interface is when the EMR system can talk with the other systems in the organization. “This provides the ability to transfer information from the sending system to one or many receiving systems and allows users of different information systems to access and exchange information both in real time and batch processing”. Hebda T. and Czar P. pp.262 (2013)
There is a lot of information that a healthcare worker would need to complete prior to sending the form to the patients record. The mandatory components for the new emergency department admission form would be the patients name, date of birth, allergies, first set of vitals, and the fall assessment. These are key components to the patients health and safety. The new program would not allow the end user to complete the form and hit submit without completing these questions. Whether building an interface or just scanning the paper form to a writable document, a program with rules would have to be implemented so the form could not be submitted without the required fields completed.
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The new emergency department electronic form will be much easier for the end user to complete. When the go live date has been met, the end user would only need to click on the emergency department admission form button and complete the form. Once the form has been completed and all mandatory fields have been updated then the end user will be able to save and submit the form. This information will then be distributed to the rest of the patients record. At any given time this document will be accessible with the push of a button instead of searching for the paper form.
For the past twenty years hospitals and healthcare organizations have been moving away from paper charting to a more technological advanced way of charting. Using EMR systems will help with patient safety, better outcomes, and is more efficient for the end user (The Era of Electronic Medical Records).
With the technology of today converting a paper form over to an EMR system is the way to go. The time that it takes to convert the form, and the challenges an organization faces is a better option then paper charting. Being able to have mandatory sections of a form filed is not only beneficial to the organization but also the patient and the end user. This new way of charting is much easier to use and is not hard to learn.
References
1. . Electronic Medical Records Implementation. (n.d.).
Retreived from https://lmr.partners.org/lmr/securelogin/AboutLMR%5CLMRFAQ.htm 2. Haupt, Angela. (2011, July) The Era of Electronic Medical Records. Retreived from http://health.usnews.com/health-news/most-connected
hospitals/articles/2011/07/18/most-connected-hospitals
3. Hebda, T. & Czar, P. (2013).
System Integration and Interoperablility: Handbook of Informatics for Nurses & Healthcare Professionals (5th ed., pp 262).
Boston: Pearson.
