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Computer documentation won’t cure all problems
Make good use of available technology
For years, health care managers have been reworking documentation forms trying
to streamline the process to make it fast and
efficient to increase compliance. No one ever designed the perfect form.
Now that technology quickly is making pen-and-paper charting obsolete, will the conversion to on-line documentation be just as difficult to perfect?
Although only a fraction of health care facilities currently document on-line, those that have installed computerized charting do find that they reap many benefits.
When Jennifer Robinson, RN, MHS, patient education coordinator at Roper St. Francis Healthcare in Charleston, SC, queried various disciplines for comments about on-line documentation, no one had anything bad to say about the health care facility’s system, which was implemented in 2002.
The benefits mentioned include:
However, just because documentation is computerized doesn’t mean that staff will embrace it. Computer technology must be used fully, and systems need to fit the user and their needs.
When the on-line documentation system for patient education was designed at New York-Presbyterian Hospital in New York City, the goal was to create the familiarity of the paper form that staff had become accustomed to while making full use of technology.
It usually is not efficient to transfer the paper form to the electronic system, says Virginia Forbes, MSN, RN, program director of patient and family education. "You can design it so you have some familiarity of look and the content that is required by regulatory agencies and your own needs, but still make it more efficient to use," she says. Efficiency comes with incorporating such computer technology as drop-down menus and links to protocols or resources.
To document, staff log onto the flow sheet section and bring up the patient education documentation on the screen.
Much of the documentation can be completed from drop-down menus; however, the option of entering text also is available. drop-down menus are used to document the learner, the topic taught, the method of teaching, the evaluation of teaching, and barriers to learning. These sections are mandatory, and there is an automatic sign-off when they are completed.
For example, to document the method of teaching, the educator could select from a drop-down menu with several teaching methods such as a one-to-one session or using a video or CD. Once this is documented, the next mandatory screen is the evaluation of learning.
When converting a paper form to the screen format, it is important to be open-minded and not force an exact duplicate, says Karen Guthrie, RN, MS, coordinator of patient education at Mount Carmel East in Columbus, OH.
The paper form at Mount Carmel East had a lot of sections for writing text, while the computerized documentation has a lot of point and click. For example, educational topics are listed in alphabetical categories, such as topic E-L and M-P. When a user clicks on the A-D section of topics, he or she would find topics such as angioplasty, blood transfusion, chemotherapy, and dressing change.
There’s also a screen for teaching methods — demonstration and outcomes, such as "performed independently" or "needs reinforcement."
While lists are convenient, it is important not to make them too complex or tedious, Guthrie says. "We learned this by experience." In the past, designers went overboard on selections, providing way too many choices. She suggests including the most frequently selected categories and allowing space for text so that disciplines can provide written comment.
A close match of the paper form and computerized system can work if the form is designed with the conversion to on-line documentation in mind, Robinson says.
Staff were receptive to changes
The team designing the computerized documentation of patient education at Roper St. Francis Healthcare knew it would be well received by staff because a multidiscipline team had streamlined the paper form so that it easily could be converted to a paper version.
"The staff were very receptive to it because they were already familiar with it, and we had already had a lot of success with the paper version," Robinson reports.
However, the system does not always work perfectly from the start. Therefore, feedback from staff helps with improvements. The documentation of patient education was added to Mount Carmel East’s computerized charting system two years ago upon staff request. Staff members said it would be easier to document patient education on-line because they already were on the computer for other charting.
Each discipline has screens for charting, and patient education documentation is included in these specific sections. However, the information entered is transferred to a common screen that all disciplines have access to so that they can review teaching in its entirety.
Another improvement to the system that was made after its implementation was the addition of separate documentation screens for diabetes and heart failure. The diabetes educators said they would like more detail for diabetes teaching documentation, as did disciplines that work with patients who have heart disease.
At New York-Presbyterian Hospital, a link to teaching protocols was added when staff said that it would be easier if they could go to a source that provided information on what to teach for a particular health issue, such as managing acute pain. If a staff member is teaching on any one of 20 topics for which there are protocols, he or she can pull up that resource on the computer.
Determining if people actually are documenting patient education and where compliance is lax certainly is easier when the process is on-line, says Robinson. Instead of having to manually pull 10 charts to review documentation, those monitoring compliance can check charts from the computer moving from one patient to the next in a quick and efficient manner.
Currently, each interdisciplinary department monitors the documentation of patient education at Roper St. Francis Healthcare giving its information to Robinson, who converts it to graph form so it can review its compliance over the years. The latest results were 97% compliance on documentation, but Robinson attributes the high numbers to the fact that each department monitors its own compliance.
Before on-line documentation was implemented, compliance was high because departments are consistently focused on documentation through the monitoring process, she says.
Yet other facilities have seen an improvement in documentation by moving the process from pen and paper to the computer. Compliance increased by 30% at the campuses within Forbes’ health care system that have on-line documentation. While there are many reasons why compliance might improve, she says that the simplicity of on-line documentation makes it much more likely that staff will comply.
However, on-line documentation has not improved physician compliance. "Although all clinical disciplines are expected to document, we have a low compliance with physician entries," says Forbes. In the upgrade of the system that currently is taking place, a component on patient teaching is being added to the physician entry section. These entries automatically would cross over to a general patient education documentation section for the patient that all disciplines easily could access.
Although on-line documentation may not solve all problems associated with noncompliance, most patient education managers agree that the conversion has been greatly beneficial.
"We always had a difficult time deciding where to keep our care plan and patient education record, whether at the bedside or in the chart. Now, no matter what unit you are working on, you can easily get to the patient education documentation screen," Guthrie adds.