Software and Communication
I was approached by a few nurses and other staff this week to discuss the mobility and assist level needed for some of the patients in the ICU. The nurses would tell me, "I really want to get this patient up to the chair, but I'm just not sure how much help he will need or how to move the patient safely." I am happy to help and provide tips to other coworkers and kindly describe the easiest way for both the patient and caregiver to complete the mobility task.
As we continue the discussion, we realize how difficult it is for other disciplines (outside of physical therapy) to locate and read the computer documentation we use for our therapy notes. The assessment portion of our documentation - where the bulk of the therapy documentation is located - requires a user to click on three different tabs, scroll to the bottom of the screen and finally open the text box. This, of course, assumes the patient was seen recently for therapy. If a note was written on a Friday and the documentation is searched for on a Tuesday, it is likely you would need to update the dates.
Our entire hospital uses the same software, but therapy notes are hidden and tricky to locate, especially if you are unfamiliar with where to "click." This develops into a bigger problem with different disciplines, who have good intentions to help the patient, but cannot find what they need because so much of the information gets lost in the overwhelming software database.
We are transitioning soon to a paper-less documentation system; where all information regarding a patient can be found in the computer. It seems to me as though the software we use has indeed provided many benefits to documenting a patient's hospital stay, but still has some areas to improve upon, especially for providing clear information in an easily accessible manner. In several instances, I have tried to locate a patient's biopsy results, latest consultation or the outcome of a care conference - and simply could not track down the information.
What do you think? Is your documentation system easy to use, and easy for RNs, social workers and other disciplines to locate and read? Do you think your software is more complicated than it needs to be? What kind of software is best for a hospital setting?