Hand-held computers to help nurses Better recordkeeping is hospital's goal

April 01, 1996|By JACKIE POWDER | JACKIE POWDER,SUN STAFF

Nursing at Carroll County General Hospital is poised to enter the computer age.

Instead of writing a patient's vital signs on a hospital chart, nurses soon will be entering the information into hand-held computers, making a patient's hospital record immediately available to physicians and lab technicians.

"Since day one, nurses have collected all the data on patients -- anything that happens is documented in a chart," said Linda McNeely, Carroll County's General's new information specialist.

"We want nurses to be able to use a computer to record the same information they now document by hand," she said. "A typewritten word is certainly much clearer to look at than handwriting."

The project is part of a continuing effort by the hospital to computerize all of its data-oriented operations. Since 1991, Carroll County General has spent $2.4 million to computerize its lab, radiology, pharmacy, dietary and therapy departments and its patient billing system. Installation of the new nursing system, and the purchase of hardware and software, is expected to cost about $536,000.

Computer improvements at the hospital so far have made it possible for staff to call up a patient's latest blood tests or medications on a computer. By computerizing a patient's hospital chart, doctors and nurses will have access to the most up-to-date information to track a patient's hospital stay, hospital officials said.

In January, Carroll County General hired Ms. McNeely to oversee the hospital's nursing computer project. She said hospital nurses may be using computers to document a patient's record by the end of the year.

Until then, Ms. McNeely said she will spend much of her time preparing nurses for the transition from paper to keyboard.

"Physicians and nurses can be against [computerization] initially, because they're used to the chart," Ms. McNeely said. "But after the first screaming and yelling, it usually goes quite well."

A pioneer in hospital computerization, Ms. McNeely began working in the field more than 20 years ago, as part of a project to computerize the National Institutes of Health in Bethesda.

Over the years she has become an expert in the specialty known as "nursing informatics." The field combines patient care with computers to streamline recordkeeping and deliver medical care more efficiently.

"It's been a fascinating experience to watch people's minds change and grow," she said. "What was cutting-edge back then is accepted as the standard now."

Nancy Chomel, a critical-care nurse educator at Carroll County General, said she expects the nursing computerization project to eliminate the transcription errors that occasionally occur when handwritten notes are transferred to a patient chart. She also hopes that the system will allow nurses to spend more time with patients, instead of scribbling notes on a chart.

Nurses are responsible for gathering all types of patients' medical information, from vital signs such as blood pressure and temperature to a patient's emotional state or response to medication.

The nursing computer system first will be installed on general patient units, then upgraded to serve the needs of specialized units, such as obstetrics, critical care and the emergency department.

Ms. Chomel said computerization will be particularly useful in these units where monitoring devices are continually taking data from patients.

The system may have a component that allows the readings to be transferred directly from the medical equipment to the computer instead of periodic readings being taken and entered in a chart, she said.

Pub Date: 4/01/96

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