- Email: [email protected]
Computerized Nursing Documentation Systems
AUGUST 1992. VOL S6. NO 2
AOKh .IOI'Rhthl.
Computerized Nursing Documentation Systems DEVELOPMENT, IMPLEMENTATION Paula Anne Latz, R N
M
any operating rooms currently use computers for staffing. scheduling. and supply management. A less common application i s using computers to complete nursing documentation forms and the operative record while in the operating room (ie. documentation actually is completed using the c o n puter during the procedure in lieu of written documentation). Com pu t e r i z i n g the s e records has many advantages: they are more legible than handwritten records. and the data are more precise. Computerized data are more easily retrievable than handwritten records. and computerized records facilitate quality assurance and other studies. This article describes how to develop and implement a computerized intraoperative documentation system.
Deivlopment
W
hen developing a computerized documentation system, a program director or coordinator should be designated. This person oversees the development of the program and coordinates different departments the program will affect (eg, surgery, nursing, anesthesia, medical records). A representative from each department should serve on a development committee to review the data entry and report segments that will be generated for his or her department. Committee members need to obtain input from and convey information to the staff members in their departments. They must keep them informed about the decisions being made, the timetable of development and implementation, and other pertinent aspects of the program. Involving the staff in planning
science ciegree i r i carcliopulnionary nursing froin St Loiris Uiii\w-sity.
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Coping with both manual and computerized documentation may be time-consuming and confusing for staff members. encourages input from the immediate users and increases staff acceptance of the system. Strong support and assistance from the computer services department or the company designing the program also is essential. There are many issues to consider and a number of decisions to make when choosing a computerized documentation system. These include what documents and records will be kept on the computer, whether a system will be purchased or developed in-house, which areas (eg, main OR, ambulatory area) will use the documentation system, and where and by whom the documentation and record keeping will be done. Required documentation. In determining what documents and records will be kept on the computer, the program coordinator first must determine what documentation and records are required. He or she must look at what currently is documented and the types of records that are maintained. It is the program coordinator’s responsibility to consider what changes to make and to predict future documentation requirements (eg, what no longer needs to be included, what is not documented but should be, what revisions in the current records need to be made, what changes in procedures or equipment, such as the use of lasers, will need to be documented). Computerized documents. The program coordinator then needs to decide which documents and records will be computerized, such as the nursing record, the OR record, the surgical log, other surgical and anesthesia reports, or any combination of records. Coping with some documentation done on the computer and some done manually may be more time-consuming, confusing, and frustrating for staff members than switching to a totally new system. Accessing data. It is easier and faster to access data from the computer than from manu-
al forms. Data entered into the computer can be retrieved for many different computer generated reports with the touch of a button, whereas paper forms must be looked up every time the information is desired. Package options. The program coordinator needs to consider which computer package to use. Options include purchasing a preexisting package that is compatible with the current system, purchasing a totally new system and program, or having a program developed that is compatible with the current system. When considering each option, the program coordinator must keep in mind what the department’s requirements are, decide how well each package fulfills the requirements, and determine whether compatibility with existing computer systems is a priority. If other departments need to access data in the documentation package, the ability of the systems to interface is essential. Customizing the package. Although purchasing a predesigned package may seem an easy solution, if the package does not meet all the department’s requirements, it must be customized. It is important to know whether the company will modify the system or whether someone in-house must do it. Even if the company will do the actual program changes, someone must work with company employees to determine the changes needed. If someone inhouse must make the changes, the program coordinator must determine whether that staff member will have time to make the necessary changes. Data entry. Different packages offer different options. The ability to enter different types of data is only one consideration. Data entry should be as simple as possible (ie, fewest number of keystrokes possible), because many nurses do not have strong typing skills. A combination of forced-choice and free-text (ie,
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Because computerized records are still new, there are no legal guidelines to govern them. word processing) options probably will be necessary. Many types of data can be entered by choosing an item from an on-screen list. For other data, narrative charting that allows the user to clarify or describe is necessary. For these free-text entries, the maximum number of characters available in the program must be sufficient for the data being entered. Screen display. The entry fields displayed on the screen should be clear and easy to read, be grouped by events that occur within a few minutes of each other, and have consecutive items displayed in the order in which they occur. It is helpful to group “always need to answer” items on one set of screens and items that are documented only for some procedures on another set of screens. Vocabulary and definitions. Vocabulary and definitions in the package must mean the same to staff members as they do to program developers. If they do not correlate, labels or descriptions may need to be altered so computerized records mean what staff members intend them to mean. A list of definitions needs to be included in the department’s policies and procedures manual. Coordinating data. Another issue to be considered is whether all areas will be included in computerization and whether personnel in all areas will enter the same data. Even though some data are the same for all procedures, some are specific for certain services or procedures, and data entry can be customized for each area. The disadvantage is that staff members who rotate need to remember which menu to use in each area or with each group of patients. Questions also arise about different standards of documentation of care for different types of patients. If the same data is not entered for all patients, it may be difficult to compile reports or compare statistics from different areas. It may be easier to develop one standard data 304
entry format to be used for all patients in all areas and to develop a mechanism that allows the nurses to bypass fields that do not pertain to the procedure being documented. Legal and security issues. Legal and security issues, including who will have access to the data, how corrections in the records will be made, who will make the corrections, what security mechanisms are built into the system to prevent unauthorized access, and what mechanism prevents erasing all or part or the record, need to be considered. Whether the data will be locked (ie, no further changes can be made after a set amount of time) and within what time frame this will occur, and whether the system will record who entered the data and display that name on the record also need to be considered. If only the data are recorded, the program coordinator needs to consider how the data will be printed, signed for, and entered into the patient’s chart. Because computerized records are still relatively new, there are no legal guidelines to govern them, and the facility’s lawyers should be consulted about package choice. Patient records. How information becomes part of the patient’s permanent record also is important. Is it printed, signed for in the OR, and placed in the patient’s chart by the circulating nurse, or is it printed out later (eg, in the postanesthesia care unit, on the ward) and placed in the chart by someone else? If the system records who enters the data, printing the record and placing it in the chart at a later time may be acceptable as long as there is a mechanism that allows the nurse to review and verify the data before it is stored. If the system does not record who enters the data, the documentation should be printed in the OR and signed for by the responsible nurse. Changing records. Who makes the corrections and additions to the records, and when are they made? Changes should be made as soon as
possible after an error or omission is discovered. If the data locks, a time frame of 24 to 48 hours is good because it allows time for corrections. Certain individuals need to have the ability to unlock records to make changes. If possible, the individual who originally entered the data should enter the changes. If the record already is in the patient’s chart, a new copy of the record should be attached to the original record. Data entry personnel. Another decision the program coordinator needs to make is who enters the data and when he or she enters it. Most of the data needs to be entered intraoperatively. The circulating nurse probably will record the data. If anesthesia data (eg, starting time, ending time) also will be recorded, the program coordinator needs to decide who will do that (eg, anesthesia personnel, nurses). Terminal location and protection. For the nurse to enter data, a computer terminal should be located in each OR. To facilitate data entry, each terminal should have the same features and keyboard configuration. Two options for computer location in the OR include mounting the terminal to a shelf on the wall, which could create access problenis if the layout of the room changes, or placing the terminal on a cart, which provides maneuverability within the reach of the cables and allows staff members to replace a nonfunctional terminal easily if quick-connect cables are used. A keyboard cover should be used to keep blood and fluids o u t of the equipment. For infection control, a keyboard cover that can be wiped with disinfectant is the best choice.
Backup System
R
egardless of how good a system is, it will be “down” at times, if for no other r e a s o n than routine maintenance. Although maintenance usually is done at night, it still can affect the OR if a case is in progress. Forms for the staff to use during computer down time need to be developed. When the system is functional again, the data can be entered into the computer. For this reason, backup
forms need to follow the same format and constraints as the data entry fields (eg, if the data entry field only allows 20 characters, only 20 characters should be written on the backup form; if the entry is a forced-choice entry in the computer, only one of those choices should be entered on the backup form). T h e program coordinator a l s o needs to develop policies about how long the system can be d o w n before b a c k u p f o r m s a r e used. Because many cases are short, the time period selected also needs to be short to ensure that data are not lost. The program coordinator also should decide who will enter the data into the computer when it is operational again (eg, a secretary, the nurse who worked on the case) and who will place the record on the patient’s chart when backup forms are used. The nurses may be more comfortable with entering the data themselves rather than depending on a secretary to do it. Having a duplicate form allows one copy to be placed on the patient’s record and another copy for later entry into the computer.
Printe n
I
f a hard copy of the report will be placed on the patient’s chart or if the surgeons need copies of the record to sign, the program coordinator must consider the location and type of printers to be used. If the hospital has a small OR suite, one or two printers in a central location may be adequate. If the hospital has a large OR suite or a heavy caseload, having a printer in each OR may be necessary. Having a printer in each OR has several advantages; if the nurse needs to print and sign a copy of the record for the patient’s chart, he or she can do this without leaving the room. Also, staff members do not have to wait for someone else to finish before they can use a printer. If the printers will be in the ORs, laser printers are a good option. They are quieter than other kinds of printers, and they produce less paper chaff, which could be a source of contamination. If the printers will not be in the ORs, the type is less crucial.
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AUGUST 1992, VOL 56, NO 2
The training mode has the identical screens and features of the program. Policies, Pi-ocedures
T
he program coordinator will need to develop policies and procedures to clarify actions and responsibilities. All decisions should be included. These policies and procedures need to be part of the development process, and in developing them, input from all affected departments is essential.
Testing, Training
A
fter the system is developed or adapted to include all departments’ needs, it .should be tested in a training mode. The training mode has the identical screens and features of the program, but it is used only with fictitious patients. This gives staff members the opportunity to test data entry mechanisms, review the program’s contents, and practice without affecting patient records. One method of testing is to have an operational terminal set up in an OR. A tester then enters the data into the computer during a case while the circulating nurse enters the data on current forms. This helps identify data that have been overlooked. It also can help identify areas where data entry is awkward or difficult or if problems exist. Having a terminal available also provides staff members with an opportunity to practice and become comfortable with the package and give the program coordinator feedback. The training mode can be used for ongoing training after the system is operational. A thorough, sound training program is essential for smooth implementation. Training should occur near the actual implementation of the system to decrease the “forget factor” (ie, if a person learns something and is unable to implement the knowledge immediately, the risk of the person forgetting the information exists).
People will need to practice using the new system so training sessions need to be held in a computer training laboratory. If a “data show” (ie, a unit that ties into the computer and displays on an overhead screen the data the instructor enters into the computer) is available, it will facilitate teaching greatly. Class sizes and number of trainers needed will depend, to some extent, on staff members’ computer knowledge. A sufficient number of trainers is needed so staff members can get answers to their questions and help with their problems as they practice. Training groups should be small (eg, 8 to 10 people) so the trainers can better assist people. T h e length of the class depends on the knowledge level of the staff members and the amount of information to be covered. An average session is 6 to 8 hours long. This allows time for instruction, demonstration, and practice. If computers are new for staff members, basic aspects of computer use will need to be incorporated into the training (Table 1). Staff members will need a demonstration of how to enter data. They also will need a practice session. One method of practice is to give each learner a patient name and then supply the class with the data to enter. The instructor can use the data show to display the correct data and have staff members compare it to their responses. Alternately, staff members can make up their own data. In addition to training and practice sessions with the computer, you need to explain the backup forms and develop a training manual. The training manual can be used during class, and it can serve as a resource manual after the system is implemented. The training manual can be used as a selfinstructional tool and should include descriptions of the system and programs and general 307
A O R I JOL‘RhAL
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Table 1
Sample Training Program Introduction A. Purpose and scope of the package B. Equipment C. Description o f class Policies and procedures A. Computer down B. Printing I . Forms to be printed 2. Correcting forms a. Before printing b. After printing C. Responsibilities Basics A. Terminology B. Basic activities 1 . Signing on 2. Menu options 3. Entering! data 4. Editing data 5 . Printing 6. Exiting 7. General points Documentation program A. Basic features B. Entering into the procOram C. Use of menus. how to enter da D. Backup system E. Printer 1. Use 2 . Basic troubleshooting Practice A. Computer B. Backup forms
operating inctructions. Data entry screens can be shown in the manual with descriptions. definilion\. and directions for completing each (Table 2). The manual also should include a 4ection describing basic functions, settings. and troubleshooting for the printers. A third section should cover correct completion of the backup forms. This should include the choices and character limitations for the forms so data can
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AUGUST I9Y2. VOL 56. NO 2
be entered into the computer accurately at a later time. The names and phone numbers of system resource people also should be included.
Implementation
T
he best time to implement a new system is at the beginning of the day shift and at the beginning of the week. At this time, staff members will have more resources available for support and troubleshooting when the system is installed. Staff members will have had some experience with the ‘‘live’’ system before the weekend when fewer resources are available. Staffing should be adjusted, if possible. so that people who are more knowledgeable about and comfortable with the system are on call. Regardless of how much teaching and practice staff members receive, they still will need a tremendous amount of support the first few weeks the system is in place. The stress of implementing a new documentation system in addition to the stress of patient care and all the situations that occur during cases will make people forget what they learced in class. They will need someone available to answer their questions and remind them how the system works. Because of the need for immediate answers to questions, multiple resource people should be available. Depending on the size of the OR suite. 1 to 3 people should be available to help staff members as they begin to use the system. Computer services people need to know that requests from and problems of OR personnel need immediate response. With thorough development and planning, implementation should go smoothly; within a few weeks, the staff members should be comfortable with the new system. Even with thorough development, minor adjustments will be necessary, because no matter how well the system is planned, some problems cannot be anticipated and will not be evident until the system is in use. The same procedure used during the initial
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Table 2
Customized lntraoperative Entry Field and data to enter 1. Surgery position Choose one of the following: lateral decubitus, left down lateral decubitus, right down lithotomy prone semi-sitting semi-supine sitting supine Trendelenberg’s 2. Position/padding (word processing format) Type in additional comments and information on padding (unlimited characters).
(Explanation: There are several other choices. The ones listed here are the most frequently used.)
(Explanation: In this field, the positioning should be fully described: positioning devices used; if padding was used; type, amount, and location of padding used; if the patient’s position changed during the procedure.)
3. Skin prep agents Choose which of the following were used: A - alcohol B - Betadine (povidone-iodine) BA - Betadine and alcohol H1- Hibiclens (chlorhexidine gluconate) HA - Hibiclens and alcohol HS - Hibiclens and saline HSA - Hibiclens, saline, and alcohol HY - hydrogen peroxide N - none PER - Peridex (chlorhexidine gluconate) PH - Phisohex (hexachlorophine) POA - povidone-iodine and alcohol POS - povidone-iodine and saline PSA - povidone-iodine, saline, and alcohol PO - povidone-iodine 4. Skin prepped by: Enter name from user file
5. Skin prep time in minutes: Enter length of prep time from 1 to 20 minutes
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development should be used when adjustments are made. Changes should be discussed with the departments involved, put into the training mode, and tested. The changes will have an impact on the system; sometimes a minor change in one area creates the need for a major change in another area. Changes will need to be made i n the data entry field and on all the report forms. During the first several weeks, the program coordinator should meet weekly with staff members about the computer system. This provides a structured mechanism for feedback, discussing concerns and problems, and conveying information about changes. Thereafter, time should be set aside periodically during staff meetings to discuss the computer. A mechanism to convey information to staff members who are not able to attend meetings also is helpful. One method is a newsletter that goes to all staff members and tells them about changes in the system and clarifies terms and definitions.
Conclusion
N
o documentation system is static. Just as with other documentation formats, computer documentation programs need to be reviewed and updated periodically to accommodate changes in practice and documentation requirements. Time spent planning all aspects of implementing the system will more than pay for itself when the implementation occurs, With up-front planning and training, a computerized intraoperative documentation system can be implemented with minimal problems. 0 Suggested reading Collins, H L. “Legally speaking: Legal risks of corn puter charting.” RN 53 (May 1990) 81.
AORN JOURNAL
Film Review
Beating the Odds of Cardiac Arrest Cardiac arrest in the OR is not common, and many perioperative nurses have never been involved in an arrest situation. It is a challenge for perioperative nurses to maintain skills required to respond to cardiac emergencies. This videotape presents key information about how to recognize and treat cardiac emergencies in the perioperative setting. Several scenarios illustrate how to recognize and treat ventricular tachycardia, ventricular fibrillation, asystole, and atrial arrhythmia. Each scenario follows Advanced Cardiac Life Support (ACLS) protocols. The author of the videotape, Donna L. Klinger, RN, BSN, CNOR, strategically uses graphics to explain defibrillator settings and drug names, dosages, and administration. The format is clear, logical, and concise. The accompanying study guide will help nurses recall and retain the subject matter. Nurses who successfully complete the posttest may receive one contact hour of continuing education from AORN. The 19-minute videotape is an excellent resource for all perioperative nurses. It provides education for staff members and will help nurses maintain the knowledge necessary to respond to cardiac emergencies. The videotape also can be used as a refresher for nurses who are ACLS certified. The videotape is available in 1/2-inch VHS for $45 or 3/4-inch U-matic for $5 1. Rentals are available for $25. There is an additional $4 shipping and handling fee for all films. Mail requests to Cine-Med Distribution Center, Davis + Geck Video Library, PO Box 745, Woodbury, CT 06798, or call (800) 633-0004. DONNA WAHOFF-STICE, RN, BSN, CNOR AUDIOVISUAL COMMITTEE
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Computerized Nursing Documentation Systems DEVELOPMENT, IMPLEMENTATION Paula Anne Latz, R N
M
any operating rooms currently use computers for staffing. scheduling. and supply management. A less common application i s using computers to complete nursing documentation forms and the operative record while in the operating room (ie. documentation actually is completed using the c o n puter during the procedure in lieu of written documentation). Com pu t e r i z i n g the s e records has many advantages: they are more legible than handwritten records. and the data are more precise. Computerized data are more easily retrievable than handwritten records. and computerized records facilitate quality assurance and other studies. This article describes how to develop and implement a computerized intraoperative documentation system.
Deivlopment
W
hen developing a computerized documentation system, a program director or coordinator should be designated. This person oversees the development of the program and coordinates different departments the program will affect (eg, surgery, nursing, anesthesia, medical records). A representative from each department should serve on a development committee to review the data entry and report segments that will be generated for his or her department. Committee members need to obtain input from and convey information to the staff members in their departments. They must keep them informed about the decisions being made, the timetable of development and implementation, and other pertinent aspects of the program. Involving the staff in planning
science ciegree i r i carcliopulnionary nursing froin St Loiris Uiii\w-sity.
300
AUGUST 1992, VOL 56, NO 2
AORN JOURNAL
Coping with both manual and computerized documentation may be time-consuming and confusing for staff members. encourages input from the immediate users and increases staff acceptance of the system. Strong support and assistance from the computer services department or the company designing the program also is essential. There are many issues to consider and a number of decisions to make when choosing a computerized documentation system. These include what documents and records will be kept on the computer, whether a system will be purchased or developed in-house, which areas (eg, main OR, ambulatory area) will use the documentation system, and where and by whom the documentation and record keeping will be done. Required documentation. In determining what documents and records will be kept on the computer, the program coordinator first must determine what documentation and records are required. He or she must look at what currently is documented and the types of records that are maintained. It is the program coordinator’s responsibility to consider what changes to make and to predict future documentation requirements (eg, what no longer needs to be included, what is not documented but should be, what revisions in the current records need to be made, what changes in procedures or equipment, such as the use of lasers, will need to be documented). Computerized documents. The program coordinator then needs to decide which documents and records will be computerized, such as the nursing record, the OR record, the surgical log, other surgical and anesthesia reports, or any combination of records. Coping with some documentation done on the computer and some done manually may be more time-consuming, confusing, and frustrating for staff members than switching to a totally new system. Accessing data. It is easier and faster to access data from the computer than from manu-
al forms. Data entered into the computer can be retrieved for many different computer generated reports with the touch of a button, whereas paper forms must be looked up every time the information is desired. Package options. The program coordinator needs to consider which computer package to use. Options include purchasing a preexisting package that is compatible with the current system, purchasing a totally new system and program, or having a program developed that is compatible with the current system. When considering each option, the program coordinator must keep in mind what the department’s requirements are, decide how well each package fulfills the requirements, and determine whether compatibility with existing computer systems is a priority. If other departments need to access data in the documentation package, the ability of the systems to interface is essential. Customizing the package. Although purchasing a predesigned package may seem an easy solution, if the package does not meet all the department’s requirements, it must be customized. It is important to know whether the company will modify the system or whether someone in-house must do it. Even if the company will do the actual program changes, someone must work with company employees to determine the changes needed. If someone inhouse must make the changes, the program coordinator must determine whether that staff member will have time to make the necessary changes. Data entry. Different packages offer different options. The ability to enter different types of data is only one consideration. Data entry should be as simple as possible (ie, fewest number of keystrokes possible), because many nurses do not have strong typing skills. A combination of forced-choice and free-text (ie,
cj, 301
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Because computerized records are still new, there are no legal guidelines to govern them. word processing) options probably will be necessary. Many types of data can be entered by choosing an item from an on-screen list. For other data, narrative charting that allows the user to clarify or describe is necessary. For these free-text entries, the maximum number of characters available in the program must be sufficient for the data being entered. Screen display. The entry fields displayed on the screen should be clear and easy to read, be grouped by events that occur within a few minutes of each other, and have consecutive items displayed in the order in which they occur. It is helpful to group “always need to answer” items on one set of screens and items that are documented only for some procedures on another set of screens. Vocabulary and definitions. Vocabulary and definitions in the package must mean the same to staff members as they do to program developers. If they do not correlate, labels or descriptions may need to be altered so computerized records mean what staff members intend them to mean. A list of definitions needs to be included in the department’s policies and procedures manual. Coordinating data. Another issue to be considered is whether all areas will be included in computerization and whether personnel in all areas will enter the same data. Even though some data are the same for all procedures, some are specific for certain services or procedures, and data entry can be customized for each area. The disadvantage is that staff members who rotate need to remember which menu to use in each area or with each group of patients. Questions also arise about different standards of documentation of care for different types of patients. If the same data is not entered for all patients, it may be difficult to compile reports or compare statistics from different areas. It may be easier to develop one standard data 304
entry format to be used for all patients in all areas and to develop a mechanism that allows the nurses to bypass fields that do not pertain to the procedure being documented. Legal and security issues. Legal and security issues, including who will have access to the data, how corrections in the records will be made, who will make the corrections, what security mechanisms are built into the system to prevent unauthorized access, and what mechanism prevents erasing all or part or the record, need to be considered. Whether the data will be locked (ie, no further changes can be made after a set amount of time) and within what time frame this will occur, and whether the system will record who entered the data and display that name on the record also need to be considered. If only the data are recorded, the program coordinator needs to consider how the data will be printed, signed for, and entered into the patient’s chart. Because computerized records are still relatively new, there are no legal guidelines to govern them, and the facility’s lawyers should be consulted about package choice. Patient records. How information becomes part of the patient’s permanent record also is important. Is it printed, signed for in the OR, and placed in the patient’s chart by the circulating nurse, or is it printed out later (eg, in the postanesthesia care unit, on the ward) and placed in the chart by someone else? If the system records who enters the data, printing the record and placing it in the chart at a later time may be acceptable as long as there is a mechanism that allows the nurse to review and verify the data before it is stored. If the system does not record who enters the data, the documentation should be printed in the OR and signed for by the responsible nurse. Changing records. Who makes the corrections and additions to the records, and when are they made? Changes should be made as soon as
possible after an error or omission is discovered. If the data locks, a time frame of 24 to 48 hours is good because it allows time for corrections. Certain individuals need to have the ability to unlock records to make changes. If possible, the individual who originally entered the data should enter the changes. If the record already is in the patient’s chart, a new copy of the record should be attached to the original record. Data entry personnel. Another decision the program coordinator needs to make is who enters the data and when he or she enters it. Most of the data needs to be entered intraoperatively. The circulating nurse probably will record the data. If anesthesia data (eg, starting time, ending time) also will be recorded, the program coordinator needs to decide who will do that (eg, anesthesia personnel, nurses). Terminal location and protection. For the nurse to enter data, a computer terminal should be located in each OR. To facilitate data entry, each terminal should have the same features and keyboard configuration. Two options for computer location in the OR include mounting the terminal to a shelf on the wall, which could create access problenis if the layout of the room changes, or placing the terminal on a cart, which provides maneuverability within the reach of the cables and allows staff members to replace a nonfunctional terminal easily if quick-connect cables are used. A keyboard cover should be used to keep blood and fluids o u t of the equipment. For infection control, a keyboard cover that can be wiped with disinfectant is the best choice.
Backup System
R
egardless of how good a system is, it will be “down” at times, if for no other r e a s o n than routine maintenance. Although maintenance usually is done at night, it still can affect the OR if a case is in progress. Forms for the staff to use during computer down time need to be developed. When the system is functional again, the data can be entered into the computer. For this reason, backup
forms need to follow the same format and constraints as the data entry fields (eg, if the data entry field only allows 20 characters, only 20 characters should be written on the backup form; if the entry is a forced-choice entry in the computer, only one of those choices should be entered on the backup form). T h e program coordinator a l s o needs to develop policies about how long the system can be d o w n before b a c k u p f o r m s a r e used. Because many cases are short, the time period selected also needs to be short to ensure that data are not lost. The program coordinator also should decide who will enter the data into the computer when it is operational again (eg, a secretary, the nurse who worked on the case) and who will place the record on the patient’s chart when backup forms are used. The nurses may be more comfortable with entering the data themselves rather than depending on a secretary to do it. Having a duplicate form allows one copy to be placed on the patient’s record and another copy for later entry into the computer.
Printe n
I
f a hard copy of the report will be placed on the patient’s chart or if the surgeons need copies of the record to sign, the program coordinator must consider the location and type of printers to be used. If the hospital has a small OR suite, one or two printers in a central location may be adequate. If the hospital has a large OR suite or a heavy caseload, having a printer in each OR may be necessary. Having a printer in each OR has several advantages; if the nurse needs to print and sign a copy of the record for the patient’s chart, he or she can do this without leaving the room. Also, staff members do not have to wait for someone else to finish before they can use a printer. If the printers will be in the ORs, laser printers are a good option. They are quieter than other kinds of printers, and they produce less paper chaff, which could be a source of contamination. If the printers will not be in the ORs, the type is less crucial.
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The training mode has the identical screens and features of the program. Policies, Pi-ocedures
T
he program coordinator will need to develop policies and procedures to clarify actions and responsibilities. All decisions should be included. These policies and procedures need to be part of the development process, and in developing them, input from all affected departments is essential.
Testing, Training
A
fter the system is developed or adapted to include all departments’ needs, it .should be tested in a training mode. The training mode has the identical screens and features of the program, but it is used only with fictitious patients. This gives staff members the opportunity to test data entry mechanisms, review the program’s contents, and practice without affecting patient records. One method of testing is to have an operational terminal set up in an OR. A tester then enters the data into the computer during a case while the circulating nurse enters the data on current forms. This helps identify data that have been overlooked. It also can help identify areas where data entry is awkward or difficult or if problems exist. Having a terminal available also provides staff members with an opportunity to practice and become comfortable with the package and give the program coordinator feedback. The training mode can be used for ongoing training after the system is operational. A thorough, sound training program is essential for smooth implementation. Training should occur near the actual implementation of the system to decrease the “forget factor” (ie, if a person learns something and is unable to implement the knowledge immediately, the risk of the person forgetting the information exists).
People will need to practice using the new system so training sessions need to be held in a computer training laboratory. If a “data show” (ie, a unit that ties into the computer and displays on an overhead screen the data the instructor enters into the computer) is available, it will facilitate teaching greatly. Class sizes and number of trainers needed will depend, to some extent, on staff members’ computer knowledge. A sufficient number of trainers is needed so staff members can get answers to their questions and help with their problems as they practice. Training groups should be small (eg, 8 to 10 people) so the trainers can better assist people. T h e length of the class depends on the knowledge level of the staff members and the amount of information to be covered. An average session is 6 to 8 hours long. This allows time for instruction, demonstration, and practice. If computers are new for staff members, basic aspects of computer use will need to be incorporated into the training (Table 1). Staff members will need a demonstration of how to enter data. They also will need a practice session. One method of practice is to give each learner a patient name and then supply the class with the data to enter. The instructor can use the data show to display the correct data and have staff members compare it to their responses. Alternately, staff members can make up their own data. In addition to training and practice sessions with the computer, you need to explain the backup forms and develop a training manual. The training manual can be used during class, and it can serve as a resource manual after the system is implemented. The training manual can be used as a selfinstructional tool and should include descriptions of the system and programs and general 307
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Table 1
Sample Training Program Introduction A. Purpose and scope of the package B. Equipment C. Description o f class Policies and procedures A. Computer down B. Printing I . Forms to be printed 2. Correcting forms a. Before printing b. After printing C. Responsibilities Basics A. Terminology B. Basic activities 1 . Signing on 2. Menu options 3. Entering! data 4. Editing data 5 . Printing 6. Exiting 7. General points Documentation program A. Basic features B. Entering into the procOram C. Use of menus. how to enter da D. Backup system E. Printer 1. Use 2 . Basic troubleshooting Practice A. Computer B. Backup forms
operating inctructions. Data entry screens can be shown in the manual with descriptions. definilion\. and directions for completing each (Table 2). The manual also should include a 4ection describing basic functions, settings. and troubleshooting for the printers. A third section should cover correct completion of the backup forms. This should include the choices and character limitations for the forms so data can
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be entered into the computer accurately at a later time. The names and phone numbers of system resource people also should be included.
Implementation
T
he best time to implement a new system is at the beginning of the day shift and at the beginning of the week. At this time, staff members will have more resources available for support and troubleshooting when the system is installed. Staff members will have had some experience with the ‘‘live’’ system before the weekend when fewer resources are available. Staffing should be adjusted, if possible. so that people who are more knowledgeable about and comfortable with the system are on call. Regardless of how much teaching and practice staff members receive, they still will need a tremendous amount of support the first few weeks the system is in place. The stress of implementing a new documentation system in addition to the stress of patient care and all the situations that occur during cases will make people forget what they learced in class. They will need someone available to answer their questions and remind them how the system works. Because of the need for immediate answers to questions, multiple resource people should be available. Depending on the size of the OR suite. 1 to 3 people should be available to help staff members as they begin to use the system. Computer services people need to know that requests from and problems of OR personnel need immediate response. With thorough development and planning, implementation should go smoothly; within a few weeks, the staff members should be comfortable with the new system. Even with thorough development, minor adjustments will be necessary, because no matter how well the system is planned, some problems cannot be anticipated and will not be evident until the system is in use. The same procedure used during the initial
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Table 2
Customized lntraoperative Entry Field and data to enter 1. Surgery position Choose one of the following: lateral decubitus, left down lateral decubitus, right down lithotomy prone semi-sitting semi-supine sitting supine Trendelenberg’s 2. Position/padding (word processing format) Type in additional comments and information on padding (unlimited characters).
(Explanation: There are several other choices. The ones listed here are the most frequently used.)
(Explanation: In this field, the positioning should be fully described: positioning devices used; if padding was used; type, amount, and location of padding used; if the patient’s position changed during the procedure.)
3. Skin prep agents Choose which of the following were used: A - alcohol B - Betadine (povidone-iodine) BA - Betadine and alcohol H1- Hibiclens (chlorhexidine gluconate) HA - Hibiclens and alcohol HS - Hibiclens and saline HSA - Hibiclens, saline, and alcohol HY - hydrogen peroxide N - none PER - Peridex (chlorhexidine gluconate) PH - Phisohex (hexachlorophine) POA - povidone-iodine and alcohol POS - povidone-iodine and saline PSA - povidone-iodine, saline, and alcohol PO - povidone-iodine 4. Skin prepped by: Enter name from user file
5. Skin prep time in minutes: Enter length of prep time from 1 to 20 minutes
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development should be used when adjustments are made. Changes should be discussed with the departments involved, put into the training mode, and tested. The changes will have an impact on the system; sometimes a minor change in one area creates the need for a major change in another area. Changes will need to be made i n the data entry field and on all the report forms. During the first several weeks, the program coordinator should meet weekly with staff members about the computer system. This provides a structured mechanism for feedback, discussing concerns and problems, and conveying information about changes. Thereafter, time should be set aside periodically during staff meetings to discuss the computer. A mechanism to convey information to staff members who are not able to attend meetings also is helpful. One method is a newsletter that goes to all staff members and tells them about changes in the system and clarifies terms and definitions.
Conclusion
N
o documentation system is static. Just as with other documentation formats, computer documentation programs need to be reviewed and updated periodically to accommodate changes in practice and documentation requirements. Time spent planning all aspects of implementing the system will more than pay for itself when the implementation occurs, With up-front planning and training, a computerized intraoperative documentation system can be implemented with minimal problems. 0 Suggested reading Collins, H L. “Legally speaking: Legal risks of corn puter charting.” RN 53 (May 1990) 81.
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Film Review
Beating the Odds of Cardiac Arrest Cardiac arrest in the OR is not common, and many perioperative nurses have never been involved in an arrest situation. It is a challenge for perioperative nurses to maintain skills required to respond to cardiac emergencies. This videotape presents key information about how to recognize and treat cardiac emergencies in the perioperative setting. Several scenarios illustrate how to recognize and treat ventricular tachycardia, ventricular fibrillation, asystole, and atrial arrhythmia. Each scenario follows Advanced Cardiac Life Support (ACLS) protocols. The author of the videotape, Donna L. Klinger, RN, BSN, CNOR, strategically uses graphics to explain defibrillator settings and drug names, dosages, and administration. The format is clear, logical, and concise. The accompanying study guide will help nurses recall and retain the subject matter. Nurses who successfully complete the posttest may receive one contact hour of continuing education from AORN. The 19-minute videotape is an excellent resource for all perioperative nurses. It provides education for staff members and will help nurses maintain the knowledge necessary to respond to cardiac emergencies. The videotape also can be used as a refresher for nurses who are ACLS certified. The videotape is available in 1/2-inch VHS for $45 or 3/4-inch U-matic for $5 1. Rentals are available for $25. There is an additional $4 shipping and handling fee for all films. Mail requests to Cine-Med Distribution Center, Davis + Geck Video Library, PO Box 745, Woodbury, CT 06798, or call (800) 633-0004. DONNA WAHOFF-STICE, RN, BSN, CNOR AUDIOVISUAL COMMITTEE
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