There are several needs for information systems in my current work place. One huge need is to transition from paper charting to computer based charting. There is wide variation in how things are charted, hand writing can be ineligible, and important details can be missed. Computer based charting could provide more structure to nurses charting, time could be saved, and important details preserved if computer based charting were implemented.
While the problem is specific to nursing, APRNs and physicians could also benefit from a better charting system. A better record could provide a very useful tool for the nurse practitioners and physicians to use when planning care for patients. Currently, several different records exist, making looking up information for one patient difficult. With a computer based system, programs could be written to run reports on different aspects of patient care in a more organized, uniform fashion. For instance, when developing a feeding plan for an infant, it would be useful for the NNP to be able to quickly review how successful feedings were for the past 24 hours. With the current system, the practitioner must review the hand written flow sheet and hope that the nurse from the previous shifts have recorded how well the infant fed. Hypothetically, with a computer based charting system the nurse would have a place to record details of the feeding that the practitioner could then easily access and get a clear picture on how to proceed with the feeding plan. This is just one example of how computer based charting could improve patient care.
I would enjoy being part of a team set out to either assist in developing or take part in reviewing current programs available for computer based charting in the NICU. I am genuinely invested in providing the best care possible and providing tools to make the job easier for the entire health care team. Nursing plays a huge role in patient care in the NICU and their charting could be much more usable in an electronic form.
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