As a former charge nurse two of my major concerns were whether or not my residents had a bowel movement and their intake for meals. Now, picture this, 5 or 6 nursing assistants in a corner, with a messy loose leaf notebook, complete with smudges. It’s 5 minutes before time to clock-out and there is no overtime allowed for charting.
How does documentation get completed? By quickly copying what the NA before her charted, and so on – well, you get the picture. Accurate? Not by a long shot! Holes? You bet! Readable? No way! I never really knew what ADL level a resident was at unless I asked them. So if that resident required more assistance for a few days, something that could have raised my reimbursement rate, well-needless to say, the higher rate was never achieved. I & O’s and vital signs were written on scraps of paper and often just not done. Elevated temps? Well, recorded, again on a scrap of paper with – was that Mrs. Smith, no, I mean Jones? Well, which was it?!
Enter the era of automation! Now imagine updating the CNA documents at the point-of-care using a kiosk or a tablet. All of that information flows throughout the eChart, and assists in filling out the MDS. No copying, no holes. Only accountability, and CNA pride in knowing the documentation was done, the RUGS scores have gone up and they were a very vital part of the process. Real time, correct up-to-the-minute charting. No errors, no holes, no messy notebook! Just touch the screen on the correct answer. How easy is that?
I can view the ADL’s, meals, vitals and behaviors when the CNA is charting. I & O’s, meal intake? I have the ability to view these in real-time as they are being charted. My RUG scores go up significantly because my CNA is charting every encounter at the point of care. My elevated temp? Well, that shows up on my alerts panel and QuickView screen. I can also check my internal e-mail and receive any resident specific messages right there at my kiosk. Efficient, intuitive, time-saving, reimbursement-raising, and easy to use – that’s Optimus EMR!