Wednesday, March 09, 2005

Hospital EMR and med admin times

See this by MedPundit:
Nurses are required to record (chart) administration of medications contemporaneously. However, contemporaneous charting requires time when there is little time available. Computerized physician order entry systems compound this challenge considerably. To chart drug administrations, nurses must stop administering medications, find a terminal, log on, locate that patient’s record, and individually enter each medication’s administration time. If medications are not administered (eg, patient was out of the room), nurses must scroll through several additional screens to record the reason(s) for nonadministration.
Why not use barcodes and scanners? I have seen wireless systems with terminals on rollers (the company called them "Nurse on a stick") like IV poles. Put one of these on a med cart with a scanner, scan the barcode on the med and the one on the patient's wrist and the system automatically records the drug administration in the computerized MAR. Likewise, vital signs can be entered into the system by the machine taking them, just scan the patient's bar code.

Of course, an advantage to paper records or post hoc entry into the computerized system is the ability to "adjust" the time things are done (or at least the time something is recorded as having been done.)