Winning the paper chase. Bedside terminals help clear the record

In a simpler bygone era, patient charts were nothing more than a few sheets of paper clipped together and slipped inside a light-weight cardboard file. Today, the average medical chart contains 70 pages of odd-sized forms, laboratory results, medication records, and hand-written notes. Initial attempts to alleviate the disorder and confusion inherent in hand-written charts involved the introduction of stand-alone bedside computer terminals. As hardware technology advanced, portable hand-held units became available. Both approaches failed because they still required the time-consuming manual entry of data. True automated management of patient records is now available through patient data management systems (PDMS). A PDMS can be connected to virtually any bedside monitoring device to record and interpret patient data into an easily understood and instantly accessible, centralized electronic record. A computerized charting system can allow simultaneous access to an individual chart through terminals located throughout the hospital, and physicians can access the system from their offices or homes. A PDMS cuts in half the time nurses spend charting vital signs, medications, fluid balances, and intravenous infusions. A well-documented, accurate chart ensures the hospital of correct reimbursement for services. In matters involving litigation, a PDMS provides a court-accepted electronic chronology of a medical case.