Charting systems in nursing homes are the current standard that determines how technologically savvy a nursing home is and whether or not a long term care facility is compliant with the HITECH Act, a piece of legislation that was signed into law in 2009 to promote the adoption of health information technology (EHRs and other healthcare charting systems).
Charting systems in nursing homes are provided by different vendors, which is why nurses must have adequate training on how to use charting systems in nursing homes. In addition to EHR training, nurses must also understand how charting is done in compliance with regulations. Some tips that nurses can follow to make documentation in charting systems in nursing homes easier include:
- Make quick HIPAA-compliant notes on the go: As caregivers provide care to residents throughout the day, it can be helpful for them to take quick notes in the charting system. This will record the essential details, which is useful if they cannot immediately document care in a charting system.
- Utilize the automation tools in the long term care software: There are several automated nurse charting resources that can save time when documenting care. Many nursing home software systems come with resources that automatically generate progress notes, care plans, and incident reports.
- Refrain from adding your opinion to charting systems in nursing homes: A medical record is not a place for nurses to record their personal opinions. Nurses should always be objective when documenting in charting systems in nursing homes.
- Chart while thinking about the future: When nurses are documenting in charting systems in nursing homes, they should always think about how the documentation will be used in the future. For example, if they or a different nurse is to read the documentation down the line, would it be easy to understand the care services provided to residents? If not, they should strive to make the documentation clear and concise.
10 Reasons to Use Charting Systems in Nursing Homes
Today, charting systems in nursing homes exist in the form of EHRs and other similar long term care software systems. Therefore, we need to understand why administrators and nurses should consider using a long term care EHR. Some of the reasons nursing homes consider implementing an EHR include:
- An EHR provides accurate, up-to-date data on residents when needed: One of the most important aspects of an EHR is that it gives nursing staff access to accurate, up-to-date information on each resident. This is essential to the quality of care given to residents, as up-to-date information allows nurses to tailor care plans according to the latest information.
- Charting systems provide quick access to resident information: Another benefit of using a long term care EHR is that it provides quick access to resident information. This is especially helpful in emergency situations, where time is of the essence.
- Enables secure sharing of resident information between healthcare providers: Charting systems in nursing homes allow for the secure sharing of resident information between healthcare providers. This is essential, especially during resident transfers when medical errors are more likely to happen. Information sharing also facilitates coordinated care, should the nursing home resident require services provided by an external healthcare provider.
- Allows for accurate diagnosis and reduce medical errors: Charting systems in nursing homes facilitate accurate resident medical records because care is charted during the point of care. This allows facilities to accurately record, diagnose, and reduce medical errors.
- Improves nurse-resident interactions: Nurse-resident interactions can be vastly improved by using nursing home software, as it provides access to information that helps nurses understand each resident’s preferences and needs. Examples of residents’ preferences include food preferences and general interests about what movies, series, or board games they like. When residents feel heard, they are more inclined toward nurses, happier with their quality of care, and consequently content during their stay in the facility.
- Enables safer medication prescriptions: Charting systems in nursing homes help to ensure that the right medication is prescribed to the right resident. Additionally, the best ePrescribing software can offer drug interaction warnings, which further increase resident safety.
- EHRs promote legible and accurate documentation in nursing homes: One of the main issues with paper records is that they often contain illegible handwriting, making documentation hard to understand. EHRs promote legible, complete documentation, as nurses can type in information directly into the system.
- Improves workplace efficiency and worker productivity: Charting systems in nursing homes can help to improve workplace efficiency, as they make documentation faster and allow for the quick retrieval of resident records. This means nurses can spend more time with residents and provide them with quality care and a high quality of life.
- Enhances resident data privacy and security: The privacy of resident data is a major issue today. EHRs offer security features such as password protection and user permissions, which help protect resident information from unauthorized access.
- Reduces costs: One of the biggest benefits of charting systems is that they help reduce costs. This is because long term care software systems come with instinctive tools that automate many tasks that are traditionally done manually, like documentation, billing, and coding. Additionally, EHRs can help to reduce paper waste and storage costs.
How To Move From Paper to Electronic Medical Records
Having read all the benefits of long term care software to nursing homes, administrators may consider moving from paper to electronic medical records. To do so, they must first plan ahead and survey staff to see who is comfortable using computers, who has past experience using charting systems in nursing homes, and what type of training may be needed. Additionally, it’s essential to have a clear understanding of the features and functionality that the facility will need from an EHR system.
Administrators must take into consideration the type of facility they oversee, as this will impact their software needs. For instance, a skilled nursing facility will have need to document far more complex care than an assisted living facility. Hence, long term care facilities should create a list of requirements and what results they expect to gain from their long term care software. This will allow decision-makers to look at software vendors more objectively when deciding which software can meet their requirements.
Finally, administrators need to be mindful of the paper records that hold all of the residents’ data. This information has to be transferred to the new nursing home software and then destroyed to protect the residents’ privacy from being lost or stolen.
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The Difference Between EHR and PHR
The difference between EHR and PHR is often discussed in the context of charting systems in nursing homes. EHRs (electronic health records) are nursing home software systems that contain the same information found in paper charts, such as demographics, medications, allergies, lab results, and immunizations. In addition, EHRs often have additional features, such as the ability to send secure messages, order tests and prescriptions, and the ability to schedule medical appointments.
PHRs (personal health records) are a patient’s individual records of their health information. Unlike EHRs, PHRs are not maintained by a healthcare provider. Instead, PHRs are created and managed by the patient themselves. Patients can add information to their PHR, such as their weight, blood pressure, and cholesterol levels. PHRs can be a useful tool for patients to track their own health information and share it with their healthcare providers.
The above information can prove to be helpful when transitioning from paper to electronic medical records. This is because when transitioning from paper to computerized documentation, administrators need to understand the difference between the two and decide if they would also like to have a PHR for their patients/residents.
The Importance of Using Charting Systems in Nursing Homes
While some have yet to make the switch to charting systems in nursing homes, it is clear that the benefits far outweigh any perceived drawbacks. Not only does electronic charting save nursing homes time and money, but it also provides improved security and accuracy.
Making the switch to electronic charting can be a daunting task, but with proper planning and execution, it can be a smooth transition. If you are a nursing home administrator who is considering the switch to electronic charting, we recommend that you first understand the difference between EHRs and PHRs. Once you have a clear understanding of the two, you can then decide if you would like to implement an EHR alone or combine the use of both EHR and PHR systems in your nursing home.