Vice President of Clinical Strategies
Paper charting might be a comfortable and familiar process; however, with the direction the ASC industry is heading, it’s challenging to keep up with the growing demand of patients and physicians and maintain these cumbersome processes.
Here are three significant issues with paper charting that electronic medical records will resolve.
Problem – Workarounds for completing charts cause ethical and legal implications.
Many clinicians feel that the timeliness of signatures and chart completion is bothersome and irrelevant to the quality of care. Using paper charting allows for opportunities to cut corners. For example, it’s not unusual for a clinician to make a copy of one completed intra-op record in advance and fill in only a few items that change throughout the day – perhaps signing things before or after and even completing and altering the chart long after the day of service. This flexibility has legal and ethical implications, and these opportunities could be circumventing the Federal, State, and their own center’s policies and regulations. When the chart is completed without audit logs and date/time stamps, all clinicians can find themselves and the documentation of their care in jeopardy.
Solution – Unique logins and time stamps eliminate workarounds and mitigate risk.
Every clinician and every user of the electronic health record (EHR) has a unique login and password, so every entry they make is automatically time/date stamped. There is never a question of when an order was given and when it was completed. No other individual can alter or access the documentation without their identity known and the time of edits tracked. The timeline of care and the security of knowing the information entered can be audited and traced provides all clinicians with comfort and assurance that what they documented is unaltered.
Problem – Information silos and segmented data.
When charting on paper, it is not uncommon for each team member to have their piece of the record and then have the Medical Records department assemble the charts after the case is completed. This is concerning as the other team members likely did not read entries made by staff in pre-op before assuming patient care. Something as serious as an updated allergy or patient limitation may never get communicated. And even if they are communicated, the legibility and location of the data are often different with each clinician. These silos can have a very negative effect on patient care, safety, and outcomes.
Solution – Information is accessible at any time by all team members.
Electronic charting removes the information silos and unifies all team members across all departments. HST eChart allows all users to communicate legibly, consistently, and simultaneously about the patient status and care in real-time for improved outcomes. The clinical team designed the chart layout so that everyone would know where to find the vital information. All necessary data is included in the workflow, so there is no need to search for it. With HST eChart, pertinent information updates across the chart via LiveEdit, and all users providing care to that patient receive notification of these changes in real-time.
Problem – Storage, access, and reporting limitations
Once records are complete, they may be stored off-site or scanned into a storage system. These can be expensive and cause retrieval issues. To guide the Anesthesia team for the current surgery, access to old records might involve several other individuals locating and retrieving the old charts from off-site or searching through the scanned archived records. Since the timeliness of this information is essential, this is concerning. Also, the completed charts may be necessary for critical analytics provided to Surveyors and federal agencies like CMS and the FDA. Manual data collection and analytics can take additional staff or take staff away from patient care.
Solution – Data and reporting is immediately at your fingertips
Electronic charting provides a reduced carbon footprint. All chart data can be electronic, eliminating the use of paper, storage of paper, making paper copies of chart information, and shredding/disposing of all paper documentation.
Even better – all past visit data is at your fingertips. Clinicians do not have to wait on old chart retrieval to plan the current case plan of care. Answers to all questions – allergies, home medications, past medical history – can be seamlessly pushed forward from visit to visit. Additionally, the gathering of accurate data and statistics can happen in a few taps.
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