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EMR or Paper Charting

EMR or Paper Charting

Brittney Wilson | The Nerdy Nurse

What kind of nerdy nurse would I be if I wasn’t an advocate of Electronic Medical Records (EMR)? Not worthy of my title, at the very least. As a nerd, I am pretty much required to preach the glories of my geeky infatuations. Not only to justify my obsessions, but also to promote more growth and innovation in the tech world. Us geeks need new tech to satisfy our cravings. A slight digression, yes, but you have no doubt grown accustomed to those in my little corner of the web. (And if not, you may want to start, because I can pretty much promise that they aren’t going away.) I mention this to make it clear that I am a lover of technology. I am a promoter of early adaptation of new technologies and and always excited to see what we will be able to do next that will simplify and improve our lives.

What is EMR?

Nursing and healthcare have benefited tremendously from the implementation of technology. Let’s take, for example, something small, routine at this point even: the vital sign machine . It alone, complete with pulse-oximetry, and digital thermometer, are a huge time saver that aid in the prompt delivery of patient care. But I suppose most nurses don’t think about the fact that these innovations are a time saver and therefor allow you have more time to care for your patients. Most don’t, but I do.

I have been fortunate enough to work in a healthcare facility that had implemented EMR long before I graced it with my presence. However, there are still components of it that remain on paper, many of these duplications of items that are in the electronic chart, that cause me great frustration.

For example, we chart our vital signs electronically but also are forced (I say forced, because believe you me, I have nearly begged to eliminate this frivolous duplication) to document on a paper graphic. The increase in probability for transcription errors alone has to be astronomical. It is also just a senseless waste of time and energy.

This backwards thinking and duplication just aid in the frustrations felt by nurses who are expected to embrace electronic charting. No one wants to do work twice, and charting is no different. If healthcare providers expect for nurses to be on board with EMR (because it’s not going away, especially with the implementation of Meaningful Use and the American Recovery and Reinvestment Act of 2009) then they need to expect physicians to be on board as well.

We are stuck charting these vital signs twice because there are a few MDs who simply refuse to log into the computer to get the information. These are also the same physicians who bark at me to print discharge med recs, and lab values (both easily accessible in the EMR). I have never once been requested to print these items for a physician. It is always “I need the med recs for ‘so and so’” or “Where are the Labs for 235?!?!!?”. Never a please or a thank you, or even a “Could you?”. Its always “I need…”, “Where are…”, “Print me…”.

I will be so thrilled when we transition to CPOE (Computerized Physician Order Entry) and the entire process will be on the computer. Perhaps then we can finally get away from the redundancy of much of our current charting and have more time to care for our patients.

I recently got an email that said “Appear to have time to with your patients. Do not appeared “rushed”.” I had to laugh at this. The basis of my practice in nursing is my integrity and honesty. You want me to not appear rushed? Then don’t make me be rushed. Eliminate duplications in charting that are costing me valuable time that I could use to “Appear to have time”. I could appear it, because I might have it!

But that of course is assuming we have appropriate staffing, which can be hit of miss. Safe Staffing: a worthy topic for another day… or days.

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