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Keywords

Computerized patient record, Interactive interdisciplinary assessment, Template fields

 

Authors

  1. WENZEL, GLORIA RABBITT BSN, RN

Abstract

The transition from the paper medical record to a fully computerized patient record has not been without pain or dissatisfaction from clinical staff. An often-heard question is, "Are we working for the computer or is the computer working for us?"

 

Documenting patient care activities is a driving force in care planning, treatment, and reimbursement. Patient assessments are traditionally detailed and at least partially documented during the face-to-face interaction between the clinical staff and the patients. Historically, overprinted forms have been developed to guide the documentation of the patient responses to the assessment and care planning. The overprinted forms are lengthy, cumbersome, and available only in hard copy and, therefore, not part of a computerized patient record.

 

Tools enabling these overprinted assessments to be part of the computerized patient record are now available in the Computerized Patient Record System of the Department of Veterans Affairs. This article describes the method used by the Butler, PA, Veterans Affairs Medical Center Clinical Information Systems Coordinator to transform an existing assessment document into an interactive interdisciplinary assessment.