As the name implies, paper records involve nurses and other health care professionals recording resident medical information using physical means such as paper. This information is then placed in physical storage facilities. Subsequently, the data can be manually retrieved as needed by a nurse or physician.
A turning point in healthcare documentation occurred in 2009, when, as The balance notes the American Recovery and Reinvestment Act (ARRA) was passed. As a result, healthcare providers across the United States were allocated 17 billion dollars to modernize their medical record databases by replacing their old paper records with electronic databases.
Since the passing of ARRA by legislators, long term care facilities have had to adopt the use of Electronic Health Records (EHRs), and nurses have had to learn to use these new systems. Naturally, there are some barriers to the adoption of EHRs by nurses and nursing homes. Some, as noted in a study published in the National Library of Medicine, are:
- Time: Nurses may not take the time needed to properly learn how to use the long term care software and all its features. A free and easy-to-follow EHR tutorial would be an excellent place for nurses to start, as they transition from paper records to long term care software.
- Cost: Long term care software system is not cheap, and some nursing homes may not be open to its cost. Additionally, the cost of IT infrastructure in the nursing home could add to the cost for a care plan software or nursing home software. This can prove to be costly for smaller facilities. To remedy this, looking for a long term care EHR provider that offers relief in the form of value-based pricing could be a solution for the nursing home.
- Computer Illiteracy: It takes skill to listen to residents and record all their complaints and medical conditions in a long term care software. Nurses who have been in the long term care industry for decades may not be familiar with this new technology, and they may need basic computer training.
- Security and privacy concerns: Resident medical information is a sensitive issue for nurses and other long term care professionals. Nurses have been skeptical of eMAR software security, and they are not alone. According to Fierce Health, more than 96% of consumers worry about the security of their financial information on EHRs.
- Complexity: If an assisted living software system has a non-user-friendly interface and is hard to use, the complexity discourages nurses from using it.
- Lack of incentives: For long term care facilities struggling to incentivize nurses to use EHRs, financial rewards for quality improvements and public reporting of performance measures can help encourage other nurses in the facility to make use of EHRs.
- Technical support: A lack of technical support can make the use of EHRs frustrating and discourage its use.
- Reliability: Reliability refers to the dependability of the nursing home software and how much nurses can trust the EHR to perform as expected. When nurses perceive a long term care software system to be unreliable, they will not use it and will revert to the use of paper records
- Speed: If an EHR does not allow for the quick retrieval and entry of patient information, it will become a barrier to its use.
Implementing a new system means understanding the people it will involve. “You have to take time to find out how people do things,” said Annette Greely, president and CEO of Jones-Harrison Residence, “Then, you have to gauge people, how they respond, and how you can implement the needed changes.” She recently appeared on the LTC Heroes podcast to discuss her experience in Problem Solving through Change Management:
5 Effective EHR Documentation Strategies for Long Term Care
A recent survey conducted by Reaction Data found that EHRs were the biggest contributor to stress and physician burnouts. As long term care software documentation is becoming increasingly common, having a standard documentation strategy in nursing homes can help reduce stress in nurses and physicians. The American Academy of Family Physicians recommends the following EHR Documentation strategies for long term care facilities:
1. Maximize the Use of Templates and Smart Phrases
Nurses should employ the use of templates for:
- Resident visits
- Patient instructions
- Medications administered
- Lists of numbers (blood pressure readings, resident weight, etc.)
Templates make performing repetitive tasks easier for nurses, as they don’t have to re-write unnecessary information. This can prove to be particularly helpful, especially when it comes to paper charting.
Your team can also use smart phrases, or, blocks of text that can be copied and pasted into an eMAR software to automatically create discharge papers. The American College of Emergency Physicians provides examples of smart phrases that physicians might use in a care plan software.
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2. Learn to Type Quickly or Employ Typing Assistants
Nurses in today’s world must be able to type faster than they can write, as it eliminates the need for short handwritten notes and allows them to efficiently record observations. Unfortunately, the nursing world is not quite there yet. NCBI notes that a study on typing skills of physicians at New York Methodist Hospital (NYMH) found that of the 104 participants, 60% of the residents lacked care plan software typing skills.
The use of assisted living software and senior living software systems will only continue to increase, and a lack of typing skills in nurses may reduce the time spent caring for residents. Typing assistants or transcription software can help make the documentation process easier for those lacking typing skills. Still, nurses must remember to always check for errors when using such software.
3. Add Short Notes
Long paragraphs will make documentation harder for others to read. When caring for residents, nurses should take short notes of any additional observations. These short notes should accompany important resident medical information.
4. Gather Data From Questionnaires
Questionnaires can be a great way of gathering data from residents. Instead of nurses manually asking each resident questions, they can administer questionnaires and have residents fill them out. This can be an excellent way for nurses to keep track of the quality of care and get feedback on any problems residents may be facing.
5. Write Problem Lists
A problem list is a document that provides a comprehensive list of patient or resident problems, all in one place. Problem lists contain a list of illnesses, injuries, allergies, and other factors that may affect a resident’s health in a nursing home. When developing a problem list, AHIMA recommends some national problem list guidance standards that nursing homes can consider, such as:
- The Joint Commission: This standard requires long term care facilities to update their problem lists whenever there is a change in medications, diagnoses, allergies to medications, or when a medical procedure is performed.
- ASTM International: This standard requires all problem lists to contain past and present diagnoses, the physiological states of residents, potentially significant abnormal physical signs, laboratory findings, disabilities, and unusual conditions.
- Health Level Seven International: This model acknowledges that problem lists change with time and may be maintained over an individual’s life.
11 Advantages of EHR That Encouraged Its Adoption by Jones-Harrison Residence
Located in Minneapolis, Jones-Harrison Residence is a non-profit long term care provider that began operations in 1888. Recently, they considered the move from paper records to a nursing home software. But this posed challenges, as paper records in healthcare had been part of the organization for over 133 years.
To make the move to an assisted living software, facility managers had to consider the disadvantages of paper records vs. electronic records in addition to the advantages. As Greely explains, it is not an easy process. “You have to sit down with the important players and the staff and explain the need to move from paper to a new system,” she said. “It’s a hard discussion, as some people love the control and comfort of paper, but you have to push them and say that it’s time to move on from that old model.”
So what are some of the benefits of long term care software that Greely and her staff had to consider? According to HealthIT, eleven of the greatest advantages of EHRs over paper records are as follows:
- Accurate, up-to-date resident information: EHRs allow any changes to a resident’s medical condition to be easily updated by nurses.
- Quick access to medical information: Nurses can quickly and easily search for resident medical information through database queries and search terms. As all the data is stored in a computer, it can be quickly retrieved for use.
- Easy sharing of resident information for coordinated, efficient care: When a resident is cared for by multiple nurses or physicians, it becomes increasingly difficult to make sure everyone is on the same page. With an eMAR software system, any changes made by one of the caregivers will be updated and seen by the other caregivers. Additionally, residents being transferred from one facility to another can easily have their information shared via the internet to the new facility.
- Improved diagnoses and resident outcomes: When nurses and physicians have access to more accurate information stored in their EHRs, they provide better care for residents. This results in better outcomes.
- Stronger resident and provider interaction and communication: EHRs allow nurses to easily keep track of resident concerns and queries, improving communication between nurses and residents.
- Safer and more reliable prescribing: Prescription medication interactions and allergies can threaten residents’ health. Practice Fusion notes that a benefit of EHRs is that they allow for easy comparison of newly prescribed medications with resident information. In addition, if a prescription could potentially cause an adverse reaction, the EHR can alert the nurse of this, preventing medical complications.
- Streamlined coding and billing: An EHR’s functions allow for the automation of the coding process and automatic generation of financial reports and statements for billing. This can save time and prevent errors.
- Greater privacy and security of resident information: Most nursing home software systems are cloud-based, and their data is encrypted. As there are no physical copies of resident information, only those with the appropriate credentials can access resident data.
- Enhanced productivity and work-life balance: Webmedy notes that EHRs can result in increased productivity in nursing homes, as they enable remote collaboration between long term care professionals. Also, EHRs enable flexibility and work-life balance, as resident care reports can be reviewed from the comfort of one’s home.
- Improved business efficiency: Long term care software systems allow for the electronic reception of lab results, centralized chart management, automated coding, and claims management. All these serve to increase the efficiency of the business and allow for more reimbursements.
- Lower costs: Record Nation notes that short-term cost benefits of EHR include reduced storage cost of files and a reduced number of employees needed for storage and maintenance. Long-term cost benefits include paper savings and reduced cost of paper-related equipment like filing cabinets, printers, and copiers.
8 Disadvantages of Paper Records
The passing of the American Recovery and Reinvestment Act (ARRA) ensured the phasing out of paper records in health care. Even before that, though, paper records plagued the long term care industry in a number of ways. True North states that the disadvantages associated with paper records include:
- Non-scalable storage
- Lack of backups
- Limited security
- Time-consuming to use, store and retrieve information
- Lack of clear data version history
- Costly to maintain
- Inconsistency of layouts and formats from one record to the next
Due to these disadvantages, the vast majority of facilities have moved away from paper records. According to the National Center for Health Statistics, eighty-nine percent of office-based physicians are using an EMR or EHR system. Still, there is a transition to be made. Leaders in long term care, therefore, must provide adequate EHR training for existing and new staff, as HealthCare IT News notes that EHR training is the biggest predictor of user satisfaction. One simple solution is online training. Our LevelUp program provides online courses for your entire staff at no cost at all.
EHRs are a better alternative to paper records. They are more accurate, have better security, and, unlike paper, the storage of care plan software is scalable. Long term care facilities stand to gain by switching to EHRs, but they should never overlook the importance of adequate EHR training for their nursing staff. Additionally, while EHRs may be costly to implement initially, they will pay for themselves in the long run, as facilities can save tens of thousands of dollars annually on account of more efficient care, greater compliance with federal regulations, and even tax savings.