Begging for Technology

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.

Module 1 - This is Me

My name is Linda Neiswender.  I am in the Clinical Nurse Leader Masters Program.  I work at Primary Children's Medical Center where I have been developing a wound and ostomy program for the past 4 1/2 years.  I am a certified pediatric nurse and recently completed my certification is wound, ostomy and continence nursing.  Completing this certification will now allow me to focus on my studies  here at the university.
Information management is essential in all areas of nursing.  As a graduate level nurse it will be even more important as I search out information to apply to my area of expertise and as I manage the information.  Databases are useful in finding out what research has been done on the use of new products and treatments.  I will also be able to establish more efficient patient and department records.
We currently document in the patient's electronic record.  We use an Excel document to import pictures of the wound, along with our documentation.  This is uploaded into the patient's record.  When not using a picture we use free-text.  We use a scheduling program to schedule patients in our outpatient clinic.  On a corporate level we are exploring the possibility of purchasing a wound charting program.  These would enable us to document, run searches, keep statistics, generate reports and billing statements, among other functions.