Documenting patient height and weight in the EMR
Did you know…
We currently document a patient’s weight multiple times in a range of different places during their admission. However, when the EMR goes live next year, measured weight will be documented just once and can be viewed centrally by all clinicians treating the patient.
The EMR team recently completed close to 65 workshops for staff. The team is extremely grateful for the close involvement of all our Subject Matter Experts and Accountable Leaders, without whom the workshops would not be possible.
You may be wondering what actually happens in one of these EMR workshops and, while each workshop is very different, we will take you through a recent one which validated workflows and design decisions regarding height and weight documentation in the EMR.
Each workshop is different, ranging from introducing order sets, discharge workflows, documentation, to validating complex medications on the EMR system.
Before the session, our EMR analysts consulted widely with our clinicians from different disciplines and specialties to understand Northern Health’s current state. They then designed the workflow and functionalities in a test environment of the EMR (known as a ‘domain’).
In this particular workshop, there were representatives from nursing, medical, allied health and pharmacy, with workflow requested to be signed off by our nursing Accountable Leaders, Deborah Zilm and Lucia Bento.
The session started with Isah Rosal, EMR Clinical Documentation Analyst, documenting in the EMR as a nurse by using CareCompass, which is a nursing worklist.
From the CareCompass, clinicians can easily see information relating to the patient, their care team, length of stay and activities with tasks for nurses to address. Isah went on to demonstrate how the patient’s measured weight will be documented, which will be displayed in a highly visible blue banner bar at the top of the screen.
Clinicians will also be able to view past documented weights from the patient’s previous visits (known as encounters) when navigating the blue banner bar.
During the session, Jessica Hart, EMR Medications Lead, logged in as a doctor to demonstrate the medical workflow of placing a medication order for the same test patient. With our patients’ best interest in mind, if doctors try to place a weight-based medication for paediatric patients without a documented weight, a dosage calculator, as well as alerts, may pop up to notify our clinicians.
The session ended with Isah, from the nursing perspective, to confirm the automatic rule that will task the nurses to re-weigh the patient every seven days (from admission). Weight changes will be automatically updated in the blue banner bar.
The workflow was validated by the Accountable Leaders. Deborah Zilm, Accreditation Officer (Chair of Standard 6) commented she “loves that nurses will only need to document weight and height in one place in the EMR.”