Medical training encourages charting to take place as near to the care event as practical, with the key word being “practical.” In reality, clinicians and nurses often stay after shifts to do their charting, because medical data entry into the EHR is not seamless during patient care. Patient demands, alerts, and urgent interruptions may pull medical practitioners from filling out the medical chart online.
The more time that passes between the health event and the data entry, the less detailed the data input, resulting in errors. Charting errors in nursing and physician care impacts patient outcomes and creates unnecessary administrative overhead. What can be done to improve medical charting for nurses and doctors?
Benefits of Real-Time Data Entry
“Real-time electronic data is a potential treasure trove of insights, which can be analyzed to improve patient care and use nurses’ time more effectively.”
– Helen Glenister, Chief Operating Officer (COO) of The Learning Clinic1
Real-time data entry has been shown to improve patient care (particularly the identification of patients who may be deteriorating), free up more direct-care time for nurses and clinicians, and help hospitals better deploy staff and resources.
According to a study published in Nursing Times, the availability of up-to-date data can help nurses and clinicians spot patterns in data that indicate a patient is deteriorating or may have an infection.2 While some data points may automatically feed into the EHR, vital observational data from nurses and doctors are not automatically entered.
Timely electronic recording of all clinical data—including observations, assessments, and actions—gives the overall picture of a patient and provides a clear data trail in the event of a complaint or incident investigation. Real-time documentation and order entry during rounding also helps speed up care and minimize future interruptions.2
The benefits of real-time data entry are well known, but challenging to achieve in some hospitals.
Challenges to Real-Time Data Entry
Siloed technology systems, device mobility limitations, and logistical issues in some EHRs can be the biggest barriers to real-time charting. Jumping from software tool to software tool, logging on to each room’s computer, and trying to type up the information at the end of each patient round can be daunting.
“One nurse believes that since going live, EHRs have added 3 hours to a
12-hour shift.” – Laura A. Stokowski, RN, MS3
In order to chart data that is accurate, actionable, and timely, the care team must be supported with an integrated solution that allows for simplified real-time charting in the EHR/EMR.
How to Achieve Real-Time EHR Data Entry
Healthcare IT integration can be very complex, but the right technology can integrate disparate IT, clinical, telecom, and EMR/EHR systems to allow information to flow freely. The result is a cohesive, integrated clinical communication ecosystem that ensures the right information is available at the right time to support quality patient-centered care.
An ideal solution will support real-time charting with:
- Intelligent field mapping to reduce duplicate data entry.
- Voice-to-text capability to speed up and simplify data entry.
- An easy and elegant interface with all information available on a single platform; no switching between apps.
- Easy transfer of clinical notes for rapid documentation.
- Immediate delivery of critical lab and test results to the right clinician with date, time, recipient, delivery status, and read status auto-recorded to the EMR in accordance with Joint Commission requirements.
- Mobile reminders and mobile alerts that sync with the clinical communications platform.
Next Steps for Getting Started
Explore how your team can combine real-time EHR data entry with seamless care coordination in one integrated solution by speaking with a clinical communication specialist.
1. How real-time data can improve patient care, Nursing Times, Sep. 21, 2015: nursingtimes.net/clinical-archive/patient-safety/how-real-time-data-can-improve-patient-care-21-09-2015/
2. How Hospitalists Can Improve Efficiency on Inpatient Wards, The Hospitalist, Rajesh Chandra, MD, FHM, et. al., May 2014: the-hospitalist.org/hospitalist/article/126231/how-hospitalists-can-improve-efficiency-inpatient-wards
3. Electronic Nursing Documentation: Charting New Territory, Medscape, Sep. 12, 2013: medscape.com/viewarticle/810573