Paper medical charts are becoming a thing of the past in many facilities. While there are still facilities that may be using an actual chart to hold all the resident’s medical information, many are converting or are already “paper-less”. Electronic medical charting has many benefits for the dietitian and has become a welcome change!
One positive outcome with electronic charting is more legible documentation. Handwritten nutritional assessments, monthly or quarterly notes can be difficult to read depending on the penmanship of the author. Doing those assessments and basic notes can be a huge time saver when going electronic. While information still needs to be gathered before the assessment or note can be completed, having the information at your fingertips makes for a streamlined process.
It is not only easier for other disciplines to read the dietitian’s notes, but all departments can quickly access each other’s information to better care for their resident. Physician’s orders are clearly listed, medications, therapy orders, allergies, recent lab tests, history and physicals, hospital records and other pertinent information.
Hunting down weights can be very time consuming. Having all the current weights in the computer makes for a much more precise assessment by the dietitian. Weight trends can be tracked quickly and interventions can be started as soon as possible. Many electronic programs calculate the 5%, 7.5% and 10% weight changes automatically which the dietitian uses in their monthly charting and follow ups. In the past, weight changes that were hand calculated may have resulted in more errors due to the human factor.
Electronic charting can also allow for remote access which can be extremely useful if the dietitian is only there a couple times per month. If an assessment or re-assessment needs to be done, all the information is easily accessed and a plan of action with recommendations can be started in a timely manner while being in a remote location.
Electronic medical charting makes a dietitian’s job easier and more efficient. Caring for the resident is our number one goal and keeping all their valuable information organized, clear and concise can help when we develop our plan of care for them.