The Science Journal of the American Association for Respiratory Care

2005 OPEN FORUM Abstracts

Time Standards From The Conversion Of Manual Documentation To Electronic Documentation In A Respiratory Care Department

AnnaG. Kessler, CRT; John J. Hill, RRT; Respiratory Care; Joanne Baldwin, IS; Deborah Ariosto, PCS Informatics; DEBORAH Heart & Lung Center, Browns Mills, New Jersey.

Introduction: Documentation of all Respiratory Care prescribed therapy as well as patient assessments have traditionally been performed by manual transcription. The evolution of computers and electronic record keeping offers an alternative measure. This project details the process improvement conversion from antiquated written form to electronic documentation of all respiratory care driven therapies along with linkage to charging capabilities in time saving factors. The purpose of this project is to convert all Respiratory Care documents into electronic format thus eliminating costs associated therapist time, paper supplies, quick resulting as well as standardizing assessments.

Methods: An interdisciplinary team that included Respiratory Care, Information System, and Nurse Informatics developed a comprehensive documentation model to include medication administration, airway clearance devices, oxygen therapy and chest physiotherapy screens. This model standardized the process for documentation, elimination of transcription errors, and included the billing portion.

Results: Launching of electronic documentation was initiated in several stages. Model screens were placed in testing fields to determine the accuracy of the order in response to documenting against practice. The billing portion was also set-up in a test ring to comply with regulations. Therapist time pre and post implementation was the following:

Transcription entry per patient Electronic entry per patient
Documentation paper = 10 minutes Documentation electronic = 3 minutes
Charging = 7 minutes Charging = included above
Retrievability = variable Retrievability = immediate response

Conclusion: The use of electronic documentation has been proven effective in the Respiratory Care Department to document all patient data. The model utilized by DEBORAH is user-friendly, time saving and allows for improved patient care outcomes. The Therapist time is utilized more at the bedside taking care of the patient.

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