Txn Documentation in EMR

[ffriesen]

I would like to take a poll to see how many facilities have done away with the paper transfusion form and have nurses document all transfusion information in the patient's electronic medical record instead. If so, what computer sytem(s) are you using and is compliance with complete documentation better than with the paper system? Does the system have an easy way to audit the EMR documentation??

Thanks in advance for your input.

[AMcCord]

All transfusions, except Surg and ER, are documented directly into the electronic medical record here. We use McKesson's Paragon system.

Nursing service designed an electronic 'page' for the transfusion flow sheet, with input from me. If they use it correctly, it allows for very good documentation. The major problem they seem to have using it is that they do not close the 'page' after each entry. This results in everything... and I do mean everything, pre-vitals, 15' vitals, post vitals, etc...appearing under the same time stamp. This is an education issue. Those who have been properly trained (and who paid attention and who follow the protocol) have no difficulty in correctly documenting transfusions. The compliance level is about the same as it was for paper flow sheets, which is actually pretty good. (I have done a LOT of nagging!) The folks who failed to complete paper flow sheets are the same ones who fail to complete electronic flow sheets.

It is a pain for me to monitor the flow sheets, but that's more a matter of how nursing service designed the sheets (works for them, looks backwards to me) and how I have to access them. My access method is restricted by security requirements from IT - I'm not worthy to access the information through the same format that nursing uses . Oh well!

Surg and ER (and NSY, for 2 or 3 transfusions a year) are required to use the old paper flow sheets. Once completed, I get a copy and the original is scanned into the electronic record by Health Information.