Automate patient documentation with pop-up menus and mouses
System must be uncomplicated, forms configured for efficiency
Is computer technology the answer to increased compliance for documentation of patient education? It can be if the system is configured correctly, says Mary L. Bennett, RN, MS, senior systems analyst at The Ohio State University Medical Center in Columbus.
Bennett worked with a team to get documentation on-line at the medical center. The team made sure all the standards of the Oakbrook Terrace, IL-based Joint Commission on Accreditation of Healthcare Organizations were being met by the computerized documentation format.
Certain computer software makes the act of documenting more efficient. The ability to cut and paste information between notes increases the speed of documentation because information documented on a sheet specific to a discipline can be copied to a generic form so staff don’t have to document twice. Information such as a patient’s readiness to learn can be quickly copied forward if there is no change from day to day.
On-line prompts reinforce knowledge
Depending on your system, prompts and directions can be placed on-line so staff can refresh their memory on what to teach, making teaching and documentation more thorough. Reference information on policies, procedures, and protocols can be called up on the screen to reinforce the caregiver’s knowledge.
It’s also possible to configure your system so multiple users can look at a patient’s chart simultaneously. When staff don’t have to wait for a chart, documentation of patient education is enhanced, says Bennett. With the computer system that is currently being installed at The Ohio State University Medical Center, any number of people can log on to the system at the same time to document education in the patient’s record. Also, placement of a computer in every patient’s room makes documenting convenient.
"The computer documentation system is incredibly more efficient than paper documentation," adds Bennett. However, the format for the computerized documentation system is based on the paper format. If an institution does not have its documentation forms perfected, the computer won’t fix the problems, she warns.
It takes time to create a good documentation system for patient education, but the process is expedited if a paper form that works is already in place, says Virginia Forbes, MSN, RNC, CNA, patient education coordinator for New York Presbyterian Hospital and New York Weill Cornell Center in New York City.
The computer documentation format for patient education at this hospital system is currently being configured. It is based on a paper documentation form, but the electronic form will be much more flexible, says Forbes.
For example, clinicians can type information into the computerized form or use the mouse to click on choices from pop-up lists such as "Barri ers to learning," "Methods of teaching," and "Outcomes." "Pop-up lists will be customized to meet discipline-specific needs. When staff click on an item from a pop-up list, it immediately appears in the flow sheet," explains Forbes. Compliance should improve because staff won’t have to hunt for paper forms or look in various areas of the chart.
Learn new system’s capabilities
Sound too good to be true? It’s not, but patient education managers should know it takes vigilance to create a computerized documentation system that works right. Diane Moyer, MS, CS, patient education coordinator at Mount Carmel Health System in Columbus, OH, advises patient education managers to become involved in on-line documentation projects from the start. An important part of this is learning the capabilities of the system the hospital purchased, she says.
Forbes agrees: "Thoroughly understand the system you will be working with in order to design a form that will work well within the system," she recommends.
It’s also important to know the patient education documentation requirements of regulatory and accrediting agencies such as the Joint Com mission, says Moyer. This will allow a committee to determine how a system would meet these requirements as documentation is configured. (For information on how outside regulators shape patient education, see Patient Education Management, February 1999, pp. 13-16.)
"Once you understand how the system works, you need to collaborate with an interdisciplinary team to be sure that what you are identifying to be included on the form is complete," says Forbes.
The type of computerized form used would be determined by the interdisciplinary needs identified, but might include a flow sheet, history, or note format. It takes a lot of brainstorming to determine all the possible routes and then choose the route that will provide the most of what is needed, she explains.
Good training program gains compliance
"You want to make sure the documentation system won’t be complicated for the staff, or it will defeat the purpose. You want compliance," says Forbes.
Once the system is in place, training comes into play. Staff won’t be compliant if they don’t understand how to document patient education on a computerized form.
Before the computer system was introduced at Ohio State, every registered nurse on the units where it was to be implemented attended two four-hour workshops. These training sessions required them to work through scenarios to familiarize themselves with the system. Bennett also worked with each nurse one on one.
"As we were teaching them, the computers were in their units and they could simultaneously document on the paper format and on the computers. They had about three months to practice. Once we went live, it was computer-only," says Bennett. Anyone who needed additional help was given individualized teaching.
There currently is a staff member dedicated to computer education at Ohio State. Newly hired employees attend a class limited to four people in order to provide time for one-on-one teaching.
Staff education must include patient confidentiality. At New York Weill Cornell Center, where computer charting has been operational for a while, nurses are keenly aware of their surroundings and they log off promptly, says Forbes. The position and location of monitors also ensure confidentiality. Of course, no one can log onto the system without a password.
To maintain patient confidentiality at Ohio State, each employee qualified to use the computer is given an ID number. That ID number not only allows staff to log on to the computer; it also restricts access to certain portions of the chart. "We set up the forms an employee can look at or be able to document on by level," explains Bennett. For example, if a staff member was not qualified to discharge the patient, his or her ID would not provide access to this portion of the chart and the screen would read, "You don’t have the right to perform this function."
A computerized documentation system can resolve many common problems, says Bennett. For example, all documentation is legible. Also, if staff decide they need another item in a choice list used to prompt documentation, Bennett can add it to the system instantaneously. The system also provides a way to ensure abbreviations of terminology are consistent between environments, so when staff see an abbreviation they know what it means.
The computer makes documentation in the patient record consistent across the board from the clinic to the in-house patient, says Bennett.
Does everything fall apart if the system goes down? Not if you have a plan in place. "At New York Weill Cornell Center of New York Presbyterian Hospital, if the system goes down for four hours, paper is used until the end of that shift. If the system goes down for less than four hours, electronic documentation will be resumed," explains Forbes.
Sources
For more information on computerized documentation of patient education, contact:
• Mary L. Bennett, RN, MS, Senior Systems Analyst, Information Systems, The Ohio State University Medical Center, 1375 Perry St., Room 120, Columbus, OH 43210. Telephone: (614) 293-3933. Fax: (614) 293-2220. E-mail: [email protected].
• Virginia Forbes, MSN, RNC, CNA, Patient Education Coordinator, New York Presbyterian Hospital, New York Weill Cornell Center, 525 E. 68th St., Box 155, New York, NY 10021. Telephone: (212) 746-8256. Fax: (212) 746-8256.
• Diane Moyer, MS, CS, Patient Education Coordinator, Mount Carmel Health System, 5975 East Broad St., Columbus, OH 43213. Telephone: (614) 234-7106. Fax: (614) 234-7721.
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