Electronic Medical Database
Charting
- Cheryl Nelson-Conley, M.S.N., R.N. (C.N.S.), C.N.O.R. -
Electronic medical database charting is setting the gold
standard for patient care documentation by incorporating
best practice standards, organization and legibility in
an easily retrievable database. The use of computer documentation
of patient care is increasing in our technology oriented
world. The purpose of this article is to discuss the electronic
documentation of patient care using a database application.
The use of this technology increases the possibility that
an attorney has encountered or will encounter a case that
has been documented using an electronic based or computerized
method of charting.
Patient charting on paper has become a time-consuming
and tedious task. Handwritten charts can lead to problems,
including but not limited to the following:
- Documentation may contain gaps in patient care documentation
due to low staffing level and high/acute patient census.
- Documentation may not be compliant with hospital or
national standards.
- Documentation may be difficult to read due to poor handwriting.
The healthcare
providers and medical institutions of today face a seemingly
impossible challenge in managing paper patient records.
Consider the following statistics:
- The average document may be copied 19 times.
- 7.5% of all documents are lost, 3% of the remaining
get misfiled.
A database application can assist documentation of healthcare
by providing a wide range of processes to address the issues
of documentation of care by physicians, nurses and ancillary
staff by providing the following:
- Legible documentation.
- Consistency in documenting to meet national standards
of care (mandatory parameters can be established which
must be answered in order to complete/close the record).
- Flexibility in documentation by including free text
options for the user.
- ‘Real-time’ data
when medical monitoring equipment is being used as in
the OR (Operating Room) or ICU (Intensive Care Unit).
- Easy retrieval of data through reports that can be generated
from the system to provide timely feedback to providers.
- Quality Management tracking to identify sentinel events
and patient outcomes can be monitored within the database.
- Access to information can be limited to protect patient
confidentiality.
Drawbacks of electronic based or computerized charting
include:
- Applications
which are difficult to use resulting in providers and
hospitals ‘migrating’ to paper
charting or a combination in which some information is
electronically charted and some is handwritten.
- Providers who have difficulty with the use of technology
and/or that have difficulty with typing.
What does this mean to the attorney defending a healthcare
provider or healthcare facility accused of a breach in
standards of practice or patient care? What does this mean
to an attorney who is reviewing a case for a client that
believes he/she or a loved one has been harmed by the healthcare
provider or system? It is important that the attorney be
aware of the relevant pieces of documentation that may
exist in a database application and where to find them.
Specifically, documentation can include the patient record
(who documented what, when and where), quality management
reports of incidences that may have occurred while caring
for the patient, and an audit trail that might indicate
any changes/alterations in documentation such as what data
was changed, who changed the record and when that change
was made. An electronic database may also contain information
about hospital, as well as national and professional, standards
of care that are accessible by the healthcare provider
while documenting care.
When an electronic database is used to document care,
several considerations are important in obtaining and reviewing
patient documentation. First, there are many types of electronic
systems in use, including electronic medical records that
may or may not be a database. An expert in the professional
field is knowledgeable about the electronic systems in
the industry and which ones are a database and not just
a documentation system. This can be important in understanding
the process of how to obtain the requested information.
Second, an expert can determine the existence of additional
documentation components such as adverse incident tracking
and an audit trail of data entry. Finally, an expert can
then assist in reviewing the patient record and additional
documents to provide feedback, to the attorney, as to whether
or not care of the patient has met a reasonable standard.
The documentation
of patient care and the record keeping of a patient’s treatment is one of the most important
tasks and challenges that today’s healthcare provider
must face. Quality documentation is critical to the delivery
of quality medical care in a safe and competent manner.
Accurate medical records are important in determining the
effectiveness of treatment(s) and in determining the quality
of care provided. Specifically, accurate, complete and
timely documentation can assist a healthcare practitioner,
as well as the healthcare facility, in determining ‘best
practice’ standards of care. Documentation must be
correct, legible, comprehensive and timely in order to
be useful. The use of a database application to document
patient care can address all the components of care and
provide timely and accurate reporting to assist in benchmarking
and determination of standards of care.
Electronic based or computerized charting can be confusing
to someone who is not familiar with this type of record
keeping, leading to incomplete assessment regarding the
presence or absence of critical documents. An expert familiar
with electronic based or computerized charting can identify
key elements within the medical record, recognize the existence
of an audit trail and provide an opinion regarding the
likelihood that the record has been changed.
Biography
Ms. Nelson-Conley has practiced as a Registered Nurse
for twenty years in the operating room. She has an Associate
Degree in Nursing, Bachelor's Degree in Nursing and Master's
Degree in Perioperative Nursing. She has published in peer
review journals, taught nursing at the undergraduate and
graduate level and is licensed as an advanced practice
nurse. In addition, she has a national certification in
operating room nursing.
Ms. Nelson-Conley is
an implementation consultant for a software company. In addition, Ms. Nelson-Conley teaches electronic documentation to nurses and other healthcare professionals.
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