North Shore Hospital nursing notes now computerized
With some prompting by way of Medicare incentives, Cook
County North Shore Hospital is moving toward keeping all of its
medical orders and nursing notes on computer. At the March 22, 2012
hospital board meeting, RN Pam Faye demonstrated how computerization
could prevent mistakes from happening.
Medications are now individually packaged with bar codes to identify
them. When a nurse enters a hospital room to dispense a medication,
he or she scans the bar code on the medication and the bar code on the
patient’s wristband and waits for confirmation that this is the right
medication before opening the package and dispensing it.
A computer program prompts nurses to go through a list of observations
to note on patient charts, standardizing the language of the notes and
helping nurses to make sure they have checked everything they should
Nurses went online with the new program in March, and doctors will be
using the system starting next January.
If computers go down, an in-house server that backs up data every 12
hours can be accessed, and medication cabinets can be unlocked if
everything goes down, Faye said.
“The nurses have been very supportive,” Faye said, “and the
doctors coming on board are being supportive. …It’s not easy!”
The new system requires staff to learn how to do things differently
from the way they were taught, Hospital Administrator Kimber Wraalstad
Are there any drawbacks to this? Physician Sandra Stover said
delivering patient care could be slowed during busy times if not
enough computer workstations are available. Some hospitals have
computers in each room. Right now, Stover said, nurses sometimes
scribble data on scraps of paper and input it into the computer system
later. Having enough computers to go around would speed up care and
assure more accurate documentation because the computer could be
accessed when working with the patient, she said.
Administrator Wraalstad’s written report to the board states, “The
Meditech Patient Care System Module (PCS) went ‘live’ on Tuesday,
March 6, 2012. Pam Faye and Chris Silence have spent the last six
weeks training nursing staff to use this module. The nursing staff
also spent several weeks completing documentation on ‘test’ [not
real] patients to develop familiarity with the software.
“While there were some bumps, the implementation of the module went
fairly smoothly. As occurs when learning new systems, the nurses have
commented that they are slower in completing certain tasks. With more
use and familiarity, it is anticipated that speed and efficiency will
The Health Information Technology for Economic and Clinical Health Act
was signed into law in 2009 as part of the American Recovery and
Reinvestment Act. It requires health care providers to keep records
in a way that is useful and efficient. Meditech is the company that
supplies the software being used to comply with the requirements of