Information is king in healthcare. Breathing rate, blood pressure, and skin color can tell much about a patient's health, with lab work and X-rays providing even more details. Patients' information is charted—or taken and laid out in a particular format—to ensure that different medical staff can understand it no matter their shift. Today's article covers nurse charting, as nurses see patients the most, especially in hospitals. We discuss charting's importance, the advantages of using electronic medical records when charting or notetaking, and why medical-grade computers are best for this essential task.
Importance of Nursing Charting
Nurse charting, or simply charting, documents all required patient information in their medical chart. "Required" can be legal, professional, and institution-specific. Patient vitals, medications, and procedures are some examples of this information.
Nurses don't draw up a new medical chart at each patient visit; instead, they update the patient's existing one with the latest information, a critical factor in creating a robust medical record for each patient.
Nurse charting isn't an afterthought or some mindless paper-pushing. Effective documentation can:
- Contribute to patient continuity of care: In brief, what is the quality of the patient's care over time? Were they diagnosed correctly? What was their food during each mealtime? What were their medicine dosages? All these details and more must be organized, coordinated, and documented between nurses, providers, and other medical staff.
- Communicate care goals: What is the overall care plan for this patient? Charting can provide answers, especially in the nurses' notes section of the medical record.
- Reimburse insurance claims: Nurse charting records billable services and their rationale for insurance companies or other payers.
- Provide legal protection: In the event of a lawsuit, the medical records created by charting provide documented evidence of the nurse's exact involvement with that patient's care.
- Demonstrate nurse competency: Professional regulators, from the nurse's college to licensing boards, can review nurses' Subjective, Objective, Assessment and Plan (SOAP) notes and any other nursing notes on the electronic medical record (EMR) system to assess their knowledge, skill, judgment, and safe practice.
- Provide data for quality improvement: Projects to improve healthcare, like switching from paper patient records to EMR, may include reviewing medical charts to understand the care process.
Advantages of Nurse Charting with EMR
In the past, nurse charting was done on paper charts and files to track patients' conditions. Everything was handwritten, from patient information to nursing notes.
The digital transformation of healthcare ditched all that paper to move nurse charting into EMRs. The advantages are numerous:
- Speed: Nurse charting can be done faster and more accurately on a keyboard or touchscreen than by hand.
- Standard form: The fields in an EMR display precisely what's needed about the patient, such as their name, current medications, and treatment plan, all in a legible form. During charting, EMRs can alert the nurse if anything important is missing or if there's a question about specific inputs (For example, dosage).
- Shareability: In the past, patient paper records had to be photocopied and sent to all participants via fax or mail. Today, EMRs allow multiple medical personnel to look at the patient's information simultaneously.
- Point of Care: Nurse charting can be entered right at the patient's side through an All-in-One medical computer or medical tablet. There is no more hassle retrieving the correct files from the nurses' station or re-entering the information into a stationary computer later in the shift.
- Traceability: EMRs automatically date and time each entry from nurse charting and identify electronic deletions. This feature aids in circumstances like tracing unusual patient symptoms and legal investigations.
- Protect patient privacy: To comply with HIPAA regulations, medical computers have many security features, from RFID identification to Imprivata Single Sign-On. These features ensure the nurse's input from charting remains secure throughout the healthcare network.
- Greater and consistent accuracy: Built-in barcode scanners and RFID readers in medical computers can make important yet tedious tasks like patient and drug identification during nurse charting easy and with minimal error.
Nurse Charting Done Right with Cybernet Computers
Nurse charting tracks patients' medical history, progress, and care needs while in the hospital and sometimes after discharge. To ensure information accuracy and legibility, nurse charting and any notes within them are standardized, making them easy for authorized medical personnel to review.
Most of today's nurse charting is done in electronic medical records. Contact the team at Cybernet Manufacturing if you're looking for the right medical computer for your EMR system. Our team members will happily discuss the special features of our medical computer lineup, from medical grade certification to fanless design and sealed IP65 front bezels.
Do you need help finding exactly what you need? Cybernet is an Original Equipment and Design Manufacturer. We have complete control of every aspect of our products, such as network options and privacy screen protection. We're confident we can develop the configuration that's just right for your nursing staff when charting.
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