Real-time Documentation

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.

2 thoughts on “Real-time Documentation

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

    • 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.

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