It's Automagic
Less ‘paper chase’ equals greater time management and more
efficient patient care
By
Phil McPeck
October 28, 2002
Janice Falca, RN, is charting new waters for her hospital, leading physicians, nurses and other staff into the paperless world of informatics, the electronic documentation of medical care.
New employees at Paradise Valley Hospital, a 120-bed community facility in Phoenix, pass through Falca’s classroom en route to their units. First, they learn the ins and outs of e-mail, closely followed by electronic charting and order entry.
“There’s a familiarity and a comfort zone with paper,” Falca said. “When I teach the CNAs, when they do their vital signs, I actually take their pencils or their pens away. I don’t want anybody to double-document,” handwriting information and then later entering it into the hospital’s database, Falca said.
For all of its benefits, tossing aside paper requires a leap of faith that can be difficult for RNs, especially older ones. Nationally, the average age of nurses is older than 47, and like others of that generation, most did not have home computers five years ago when Paradise Valley began its informatics program.
“I have to be honest,” said Falca, 56, a former med/surg and oncology nurse. “I questioned it in the beginning. I couldn’t imagine how it was going to be better than the flow sheet that we do. But I was looking at it from a staff view. One of the things nurses have to do is look at the big picture vs. just what they only do with their patients.”
The caregivers’ hang-up in going electronic is trusting that the documentation is there. Because “in the nursing profession, if you didn’t document it, you didn’t do it. That hasn’t changed in a hundred years,” Falca said.
But reports directly put into the computer are at hand, if not in hand. It’s there to be accessed and changed, just as it was on paper, but in a far more powerful form.
“The biggest advantage is that we bring up the standardization of documentation,” Falca said. “You will always have some nurses that will be excellent documenters and others that did all right, did what they had to do.”
Computer-based forms allow RNs to catalog observations and patient interviews by choosing from a variety of set answers, while also providing a place for nurses’ notes. “We don’t have a lot of clinical documentation as of yet,” Falca said, but that is coming.
It’s what happens with the data RNs enter that makes informatics an exciting specialty and explains the Paradise Valley administration’s investment in documentation technology, Falca said.
Certain patient development triggers share information across hospital departments. For example, if a patient reports a gain or loss of weight in the last three months, the nurse’s documentation of it goes automatically (or some might say “automagically”) to the hospital’s food and nutrition services department. Documentation of a sore goes to wound care specialists and a report of weakness in the legs goes to physical therapy.
Furthermore, informatics allows hospitals to deftly manage information. In the paper world, a request for the number of male births in the last year could require physically pulling and reviewing hundreds of charts. A computer search of records takes minutes.
Likewise, a patient might see a bill for five dressing changes and contend that some weren’t done. Through a computer workstation, auditing a chart is a matter of a few keystrokes or clicks of a mouse.
“Patients actually think we’re pretty progressive,” said Falca, who more often than not is on the floor and in patients’ rooms with a handheld computer, troubleshooting and ensuring that nurses are comfortable with electronic documentation.
She also networks physicians’ offices into the hospital, allowing them to monitor patients from afar, direct care and put an electronic signature on orders.
“I think eventually nurses are going to have their own little Palm Pilots” to document care, including more clinical input than the present system allows, Falca said. “Several facilities already have wireless technology, where [nurses] just wheel in a laptop and do their assessment. We hope to be doing that by the end of the year.”