The Science of Nursing

New Technology – Electronic Clinical Documentation

Phyllis Whitener, Director of Patient Care Information Systems

On December 8, 2008 the Psychiatry units went live with Meditech’s electronic documentation system. Active staff involvement and administrator support made this a very smooth implementation. Physicians and other disciplines are also on board with the change in process, are recording Team Meeting Notes electronically in the record, and using the computer to review data and manage the patient’s plan of care.

Documentation of care (except for a few specifics such as medication and blood administration) is now recorded electronically by all disciplines for all inpatient units except Special Care Nursery and Inpatient Rehabilitation. All units use Meditech modules for documentation except Birthing Center, which uses the Phillips OBTraceVue product. Critical Care continues to use a flow sheet to record vital signs until an interface from the monitors to Meditech is completed. The Emergency Department, Operating Room, Day Surgery and PACU also use Meditech modules designed specifically for their areas.

The medication administration process will be the next focus for conversion to electronic documentation. The Bedside Medication Verification and electronic MAR project is scheduled to begin in the fall of 2009.

CVMC ‘s electronic health record is becoming a reality.