Monday, December 5, 2011

Doctor Aware” - The Integration of Nursing Notes and Physician Documentation

How does the provider keep track of the nursing notes with the use of purely electronic medical records?
Theoretically, in the “paper world” the provider would read all the nursing notes and then comment or appreciate the content. In reality, the provider rarely reads more than the initial triage assessment and nursing note. The rest of notes are kept with the nurse and usually completed long after the physician is finished with their documentation. Physicians who document after the fact on their own time, may or may not use or have access to the notes.
In the “Electronic World” the provider rarely has real-time access to the nursing notes with a single mouse click. They have to maneuver around the program to find the data (if it even there yet). Your computer program should have easy access of all data to all providers that have been granted access. This should be accomplished easily and without requiring the user to be a computer expert.

Additionally, how do healthcare providers know when the nursing notes are complete concerning the interaction with a specific provider? The notes can go on and on for “ED Boarders” when the initial provider is long gone. This is also true for discharged patients when the nursing notes are done long after the fact.

My favorite nursing notes are “Doctor aware” and “Doctor notified”. About what?????

The EMR we use attempts to solve some of these problems with simple interface like a “tab button” that allows quick access.

1 comment:

  1. "100% consistency between the notes of involved providers asynchronously entering data in the ED environment is virtually impossible to achieve. Discrepancies that might result constitute not only a safety issue for patients, but also a medical-legal risk. Nevertheless, the ED physician is ultimately responsible for being sure that all relevant information is included in the decision process. Ideally, the EHR would notify the physician of any potential discrepancies when they are added, but the technology for this has not yet been sufficiently achieved. One has to rely on human-generated communications in such instances. Safeguards might include cross-referencing flags that alert the physician to changes made that may impact the overall consistency of the record."

    - Submitted by Dr. Donald Kamens