By: Stacey Holman, Director of Clinical Products
Electronic documentation has many benefits, such as legibility, accessibility, improved coordination among clinicians, efficiency and portability of information to other systems. Facilities need to consider how the documentation system is set up, the policies and procedures for documentation and the training of clinicians. Documentation systems allow information to be copied forward or populated automatically from the previous documentation. This may help ease the burden of documentation for clinicians, but clinicians must be diligent in validating the data. With increasing patient acuity and nursing shortages, are clinicians always able to catch when information has changed and update the documentation accordingly?
Some systems allow facilities to determine what information can be copied forward based on a time frame. Others allow users to only copy “their documentation” forward. Some systems may bring forward historical information, so the information is always available. For example, if a patient had a tonsillectomy in 1982, this information does not change. However, if the person previously had “No Known Allergies” documented on the last visit but has since had an adverse reaction to Penicillin, the clinician would need to change “No Known Allergies” to “Penicillin Allergy.”
A common argument against copying documentation forward is the risk of clinicians failing to validate the copied information. For this reason, some facilities have policies that prohibit the practice while others may allow only specific information to be copied, such as surgical history. Removing/not allowing copy forward may cause some clinician dissatisfaction. For example, clinicians may want the IV site documentation to be pulled forward. However, this can be a common cause for inaccurate documentation. Here’s an example: The IV was documented as placed in the left hand for four days, but the site infiltrated on day two, and the IV has been in the right hand for the past two days.
The goal is accurate, timely documentation, and with meaningful use, healthcare providers need to share information between systems, making accurate documentation imperative. Is allowing copy forward a time-saver for your clinicians, or does it enable “bad documentation” by some? These are things to consider when writing policies and defining how your EHR system is going to work best for your clinicians.
Teamwork is essential to patient care. Physicians, nurses, nursing assistants, physical therapists, dieticians, case managers and other clinicians work together to provide patient-centric care. For example, nursing assistants take patients’ vital signs and communicate the results to nurses. If a patient’s blood pressure is critically high, the nurse will communicate with the physician. The physician may order a blood-pressure medication, more frequent monitoring of the patient’s vital signs, as well as a lab test or other procedure. The physician’s orders are communicated to the appropriate providers in the hospital. Medication orders will be verified by the pharmacist, and other providers will complete the ordered tests/procedures. The nurse will then administer the medication, continually monitor the patient’s vital signs and communicate with the physician. The healthcare team is vital to the patient-care delivery process.
As with patient care, teamwork is vital to developing healthcare software. Subject-matter experts (SMEs), developers and quality assurance (QA) analysts are essential to the development process. SMEs are nurses, lab technicians, pharmacy technicians, pharmacists and physicians. The SMEs at HMS are healthcare professionals with education and experience in roles specific to the solutions they manage. An example of teamwork is SME collaboration in the development of medication delivery solutions that streamline workflow and improve patient safety. Developers help SMEs in determining technical feasibility, impact to performance and scope. QA analysts are engaged in the development process from the beginning. They review product requirements, help SMEs with product impact and test software modifications to ensure quality solutions are being provided to customers. Continuous communication and coordination among the development team members are crucial to providing software solutions to help clinicians.
Providing patient care and developing healthcare solutions require team collaboration. Constant communication, brainstorming sessions, status checks, as well as a continual review process, improve the development process and healthcare solutions. Whether at the point of patient care or the development of patient-care tools, the benefit of collaboration in healthcare is improved patient care.
Frank Newlands, M.D.