The new program is an upgrade of the current electronic patient record documentation system. A new feature of this program is the direct physician order entry. The physician will now enter the order in the new documentation system that goes directly to various disciplines or departments where it is reviewed and processed. For example, the patient’s diet order will go to the dietary department where it is reviewed, processed and the diet is delivered to the designated unit. When the physician orders medication, the pharmacist will review it, and sends the medication to the designated unit. This direct order from the doctor to the pharmacy will ensure that the correct medication and dosage is delivered for the nurse to give to the patient. Because the pharmacist is the one who interprets the doctor’s order and it is the pharmacist who verifies the order. With this new process of medication transcription, a medication error is most likely minimized or eliminated. The EPRDS facilitates review of the patient records, advocacy of the patient’s needs, and collaboration of nursing care with other disciplines because duplication is reduced thus time is well spent. In addition, because it is a digital record, time is saved by not having to search through paper records. In addition it is cost effective to the organization.
However, there is a new challenge that arises among the staff in the use of the new electronic documentation system. Learning the new icons and the new format can be tedious and time consuming. Combining computer proficiency and fulfilling direct patient care can be challenging each day. Spending time just completing the documentation on the computer leads to less time spent at the bedside. A good knowledge and application of time management skills is very important.
According to Stephen Covey, who wrote the book on “The 7 Habits of Highly Effective People,” time management is the ability to “organize and execute around priorities.” When providing patient care at bedside, nursing tasks must be prioritized in order to provide safe patient care. Direct patient care, patient education, and especially nursing documentation are the important aspects of a nurse’s daily routine and must be done with accuracy. As the saying goes in nursing, “If it is not documented it is most likely not done.” Additional activities such as attending committee meetings, making nursing referrals, and attending mandatory classes can take up the nurse’s time and delay completion of nursing tasks. All these must be taken into consideration when organizing and prioritizing activities.
Tips for digital documentation
Just remember that time is precious. As Napoleon Hill, the famous writer said, “Do not wait; the time will never be ''just right.'' Start where you stand, and work with whatever tools you may have at your command, and better tools will be found as you go along.”