March 29, 2023

EMR and Standard 5: Comprehensive Care

On 16 February, the Electronic Medical Record (EMR) team presented on the Comprehensive Care Plan to the Assessment and Care Planning Sub Group Clinical Improvement Committee.

Northern Health’s EMR, designed by our clinicians, aims to provide staff with better patient management and documentation, in turn delivering quality care to our patients and community. Current paper forms such as the CARE Record are built into the system where staff will be able to document information such as fall risk, patient’s expressed goals of care and healthcare needs, and will be visible to other clinicians on the care team. This reduces the time used to locate patient charts, as well as double documentation.

Daniella Chapkoun, EMR Informatics Officer and Benefits Analyst, said this was a big step forward for Northern Health as a digital platform increases transparency and reduces duplication.

“In the future, the digital equivalent of the Care Record will allow information to seamlessly flow from one area to another without double entering,” adds Daniella.

When the EMR is implemented, nurses will be able to select if certain care plans are not met, and Nurse Unit Managers will be able to follow up on the next shift.

During the presentation, we also had a consumer representative to see first-hand that the benefits of the system are appropriate from the perspective of patients and family members.

Patient information such as name, date of birth, and allergies, will be documented in the EMR when they are admitted, and will be carried over should the patient require re-admission. Currently, our patients may have to repeat their health histories and we understand it could be frustrating. With the EMR in place, clinicians will be trained to confirm health histories with patients displayed in the EMR.

“I believe EMR will be of great benefit to the patient as it will provide improved patient documentation and management of information. It will also provide quality care for the patient and community, by reducing the time to locate charts and have all information collated in a centralised place. It is very pleasing to see EMR being initiated at Northern Health and to have been a consumer representative on this project,” says Mary.

Maree Glynn, Director of Clinical Practice and Improvement, was pleased with the new change moving forward.

“It was very pleasing to see that all the hard work in developing the CARE record over the past five years has not been lost and it has been fully incorporated into the EMR. The EMR supports our accreditation requirements to develop a comprehensive plan of care for each patient that is developed and used by all of the clinical team involved in the patient’s care,” says Maree.