I recently began working in a facility with a fairly long history of EMR use. The PICC team continues to do almost all of their assessments and in, duplicate documentation, the placement information on the same old forms they used for years. These are kept in a locked office but otherwise unsecured. My belief is that we become invisible as nurses when we fail to document our assessment and decision making in the EMR. Unfortunately, this is not the first hospital I’ve worked in that follows the same practices.
Does anyone have a standardized assessment for the EMR? Is there any reason to double document insertion info in the EMR and on a piece of paper?
I do realize change will be difficult. I believe it needs to be done or we will become invisible. The knowledge and expertise needed for PICC and other vascular placement needs to be seen to be valued.
While I see your point, I would have to ask the reason for no VAD assessment and insertion notes in the EMR? Maybe this required a specific type of programming to get the spaces for the complete information. Maybe there was no easy template and there was no programmer that could creat this. I have reviewed lots of EMRs after the documents were converted to pdfs. There is a tremendous amount of problems with EMR documentation from the inserter expecting staff nurse to document to missing facts that are critically important. EMRs should offer a method to extract data for analysis of trends and identify problems. But many fall short of these goals. And don't get me started on the problems with copy and paste!
Lynn Hadaway, M.Ed., RN, NPD-BC, CRNI
Lynn Hadaway Associates, Inc.
PO Box 10
Milner, GA 30257
Website http://www.hadawayassociates.com
Office Phone 770-358-7861