Charting- the EHR years

As long as there has been modern nursing there has been charting.

Yes, starting back with Florence Nightingale.

How else would you measure improvement?

And did I tell you that Florence Nightingale was the first nurse statistician?

Yeah. She measured and remeasured the soldiers to ensure that her interventions were making the impact that she wanted. What is that but pure research?

Where there was nursing, there was charting. The noting down of a patient’s symptoms/wound size/progress toward goals kind of charting.

When I was at the California hospital, we had a hybrid system. This was 1999 after all. There was computer writing of nurse notes that would be saved to the mainframe at the hospital and physicians could read them. If the computer charting system was down, the nurse wrote notes on paper. Physical therapy and physicians wrote notes on paper.

Not all of the notes were legible, though. Most of the notes required another nurse who could read the handwriting.

Many medical mistakes were made due to poor handwriting.

Fast forward to the electronic health record.

A mere 10 years in the future.

Now there is the electronic health record that is purportedly easier to chart with.

I’ve never charted in the EHR as a floor nurse and I am not the most up-to-date on the EHR for narrative nurse notes.

Medical mistakes went down when there was a clearer way to convey progress.

EHR has some naysayers.

I quite like it.

After all, I had a hand in creating the hospital system’s EHR. I was a subject matter expert who had input into what must be included or not needed.

It has definitely cut down on complaints over my own handwriting.

I can only think it helps with patient safety.

If only from the doctor’s illegible handwriting.