I am at a new hospital which uses paper charts (I trained using EMR). There is a tracking board, computerized order entry, and inpatient records online. I am having a REALLY hard time writing good charts while keeping up with patient flow. For billing purposes, I can deal with it, but medicolegally I just feel like these charts suck. I try my best to put in some medical decisionmaking and progress notes in each chart but its so tough. Half the time I can't find the chart. Half the time I am in such a rush that my handwriting is illegible. The residents documentation sucks across the board. I try to keep reminding them to document medical decision making etc.
EMR is in the works but wont happen for probably 1 year.
Any tips on how to deal with this issue? Its freaking me out
Thanks everyone
There's no good way to deal with this. When you've trained in an EMR/CPOE environment, going to paper charts is like stepping back into the middle ages. The only way that you can maintain the sort of efficiencies that you have with EMR/CPOE is to reduce the quality of documentation.
Compare the old and the new: Physician goes in to see a patient. He/she may or may not take notes on paper in the room. The doc formulates an assessment and plan, then comes out and tells a nurse "this is what I want ordered." Eventually, results start coming back, usually on half a dozen sheets of paper. Vitals are charted somehwere else, usually on a nursing flow sheet. Eventually, the physician sits down to dictate and has to sort through all these papers for the dictation. It's like seeing the patient twice - perhaps three times.
In a new system, each ED room has a computer in it. A fast one with a good intranet connection. The physician walks in, logs in, and types while taking the history. They do a physical exam, and spend about 30 seconds documenting it. They order from the patient room before moving on to the next patient. You walk out of the room, and you're done.
The only way you can begin to approach this is with paper t-systems without dictation. Even so, you lose a lot when you start getting results back on paper.
When you look for a job, spend a lot of time looking at the charting systems and the billing systems used. They can go a long way towards making your life good - or miserable.
