I was hired into my current position 41/2 years ago, and promptly began - oh yes- hand writing notes. However, I did have an amazingly tech-savvy boss who hooked me up with the electronic medical record in the hospital. What an improvement! I was then able to type my notes, print them off, sign them, and place them in the charts. Shortly thereafter we collaborated on a new note. I provided the parameters, he provided the programming knowledge, and our electronic note was created, including the ability to import pictures into the note itself. These were uploaded into the electronic medical record, printed out in full color and, placed into the chart. Providers and staff were truly impressed. Eventually we were able to eliminate the need to print the typed note, but continue to print the picture note and place in chart. Anyone with access is able to sign into the patient's chart, click on our consults, and read all of our notes.
Another aspect of my position is participation on the corporate wound and skin team. In an effort to standardize our documentation, we have been petitioning for wound charting program. We determined the needs of our various hospitals and clinics, then investigated several companies. After much discussion and evaluation, we made our decision and submitted a request to our corporation. We are currently waiting for approval and purchase, following which we will take the necessary steps to implement the product into our practices. Once established it will need to be maintained and updates made as needed. These are some of the ways to be involved in system development.
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