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Development and Implementation of a Multi-Disciplinary Technology Enhanced Care Pathway for Youth and Adults with Concussion
Published on: January 20, 2019
Transitioning from paper to computerized documentation
Abstract:
Although charting forms have evolved over time to meet the changing needs in healthcare, little has changed in the process of documentation until the introduction of computers in healthcare in the late 20th century. The author describes three early nursing documentation systems and the evolution of the automated process. One of the important lessons learned about the move from paper to computerized charting is that the process is not "automatic."
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In an SOR, each discipline involved in patient care maintains a separate medical record section. This record-keeping method enables easy tracking of patient progress and ensures healthcare staff have access to up-to-date information.
Key Attributes include the following:
