Goodbye Paperwork! - New Record Systems Make Extra Time For Kids

Record keeping is critical in health care, but very time consuming.

Skilled Nursing Facilities, including pediatric facilities, are discovering it takes less time to update charts and review patient care when they change to paperless documentation.
Jennifer Morgan
“Less time on paperwork means more time for quality care,” says Jennifer Morgan, RN, BSN.  As Staff Development Coordinator she oversees training and the transition to Electronic Health Records (EHR) at New England Pediatric Care in N. Billerica, MA.

 “We started using computerized record keeping for doctors’ orders about a year ago.  Now the rest of the staff is able to report or review the latest information at kiosks (computer stations) located throughout the building,” she said
Reporting is quicker, she noted, because a series of questions pops up to record progress, level of assistance needed and condition changes.

“We get a clear snapshot of what’s been done immediately. It’s easy to tell what chart you are in; and there is no difficulty deciphering handwriting,” Jen said.  Staffers use unique user names and passwords to access secure records and their automatic signatures on entries ensure accountability and accuracy.
NEPC’s system currently color codes Activities of Daily Living: “to do” is yellow; completed jobs are green; red means overdue, Jen explained.  Soon the system will similarly display changes in medications and treatments when an individual’s chart is called up.

For the past two years Cedarcrest Center for Children with Disabilities in Keene, NH has been using kiosks and an integrated medicine cart to enable real time charting of meds, vitals, and activities of daily living at the facility.
Recently, following an evacuation drill, administrators decided to modify its software system to allow remote access to records, according to Jeff Fuller, Director of Development and Community Relations.

“We are working in conjunction with the pediatric clinic practice at Dartmouth-Hitchcock Keene to work out the protocols and technical issues to make remote access possible for on-call and emergency situations,” he said.
Seven Hills Pediatric Center in Groton, MA started using a simple version of EHR in 2004, and is in the process of moving to updated software.  Certified Nursing Assistants have been making reports on the new software and the rest of the staff will move in the fall, according to Holly Jarek, Vice President and Executive Director.

“Even eight years ago when the first system was introduced, we found little resistance to change because people were using computers at home.  We made this conversion without a blink. ”
Note: All nursing homes are required to implement electronic records by 2014.