Module 1 IT in the ER

The ER uses standard paper documentation. For our nursing documentation sheet, there is an area for triage, pre-hospital treatment, and the nursing assessment on the front side. On the back we are able to list given medications, ER interventions, IV starts, and free text everything else. The powerpoint on “coding and classification of clinical data” describe nursing documentation to be symbolic representation of concepts. There is a standard blank picture of a body, front a back, also of a head, that symbolically represents each patient. We use numbers and circles to identify pain, lacerations, abrasion, etc. This kind of structured documentation can help people find information faster. Everyone who is seen at the hospital is given a Medical Record Number (MRN) as an identifier and means to store hospital visit information. There has been a problem with standard identifiers when people have multiple MRNs, making it difficult to retrieve past medical interventions and medication regimes. The coding system used by physicians in the ED is recorded on discharge summaries. If other specialists and providers are in the same network, information is easily accessed; however, as in the quality of diagnostic coding study in New Zealand showed, transfer of information may be delayed suggesting inefficient coding practices. Structured/coded clinical data is useful in promoting quality patient care if correct terminologies and coding are used since it will help increase communication and management of patient data. A push towards information technology and proficiency with standard documentation and coding will promote quality of care so we can spend more time with our patients and understand their health history from the beginning of their visit.