Real-time Documentation

April 20, 2012 at 3:03 pm 2 comments

Ministry has been championing “real-time documentation”, that is, the practice of entering patient information into the EHR at the time it is collected. Historically, caregivers have clung to the old process of writing on paper and then re-entering it into the EHR later. Our Nurse Informaticians  are doing the hard work of changing that practice. In the areas where we have seen the change, the nurses are reporting that it has given them more time to spend with their patients. The elimination of transcription also means real-time documentation is a more accurate practice.

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2 Comments Add your own

  • 1. Greg Poirier  |  April 20, 2012 at 4:35 pm

    Yeah, one for technology. Curious about the initial expectations of the Nurse Informaticians vs. how they feel about the EHR now?

    Reply
    • 2. Karen H.  |  April 21, 2012 at 1:40 pm

      Many nurses and doctors I have worked with worry about the patient experience and feel that having to enter everything during the visit will take away from the 1:1 contact with the patient. I think this comes with time though. My PCP has been on an EMR for years and she does better with interaction now than when they were first implementing it.

      Reply

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About Me

This is the Blog of Will Weider, CIO of Ministry Health Care. Ministry Operates 15 hospitals, 47 clinics, a health plan and home care and hospice services. We employ more than 12,000 staff members. Our combined medical groups include more than 650 providers.

This is the place where I share what I have learned through my mistakes and other crazy things in the life of a healthcare CIO.

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