Electronic Medical Record clinician documentation is here

The Electronic Medical Record (EMR) will become the legal medical record for Admission Assessment and Flowsheets on Tuesday, April 18. As a result, inpatient nurses and respiratory therapists will be required to use the EMR as the official documentation tool beginning at 6:45 a.m.

Physicians and other clinicians will now be able to view the most current patient data: vital signs, I&Os and other flowsheet information in the EMR. Until Clinician Order Entry becomes part of the EMR next year, the Medication Administration Record (MAR), Nurses Notes, and yellow Kardex/Rand will remain on paper.

"This change in accessing and using data is the first step in a long process toward implementing UC Davis Health System's Electronic Medical Record," said Tom Tinstman, "Associate Director for Clinical Information Systems." We look forward to serving our patients better and more efficiently with each new enhancement."

Here's what health-care providers can expect to happen during the first few hours, days and weeks of this change:

• On April 17 at 7 p.m., a Patient Data Entry Form will be distributed to all the inpatient units to gather patient information such as IVs, drains, tubes and wounds. Nurses will be requested to attach the form to the patient clipboard and complete the forms prior to midnight. EMR team members will then assist staff to preload this information into the EMR. This process will allow clinicians to ease into charting on their patients in the EMR at 6:45 a.m. April 18. Patients admitted after April 18 at 6:45 a.m. will be added using the new EMR process.
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• An EMR team Command Center will be set up in the Main Hospital Room 4303 on April 17 at 11:30 p.m. to centralize communication about Admission Assessment and Flowsheets. The Command Center will be available 24/7 from April 17 through May 1. The Command Center will dispatch SuperUsers in blue EMR shirts to assist clinicians with entering Admission Assessment and Flowsheet data into the EMR. SuperUsers will be available for six weeks beginning April 18 and on every inpatient unit for the first two weeks. SuperUsers will also review selected charting elements to assist clinicians in proper use of the EMR and to identify areas needing additional training. SuperUsers will continue to be available centrally for the third through sixth week after Go-Live.
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• SuperUsers will be in daily contact with the Command Center and use an Issue Notification Form to log suggestions or identify problems using the EMR. The form will be delivered to the Command Center for action and notification to the user(s) of the resolution.

SuperUsers are still needed to sign up for shifts and are eligible for the shift bonus program for the entire six weeks. SuperUsers interested in additional SuperUser shifts should communicate with their manager and contact Laura Janik at laura.janik@ucdmc.ucdavis.edu with the shifts they are willing to work. In addition to SuperUsers, other tools are available to assist clinicians. Reference cards are attached to each of the new mobile EMR devices, and the EMR Web site has training manuals and online training available at http://intranet.ucdmc.ucdavis.edu/emr/.

Presentations and pocket reference cards have been provided for physicians to assist them in learning to how to view Admission Assessment and Flowsheet information.

After April 18, if the EMR becomes unavailable for any reason, clinicians are asked to implement the "System Unavailability" process to record patient information on paper, and then back-enter selected data into the EMR. Paper forms are located in the "System Unavailability" containers on each unit. More detailed information also is available on the reference cards, the EMR Web site and in the System Unavailability Manual located on the unit.

The following departments will continue to use their routine paper flowsheets at this time: Emergency Department, Operating Room, University Surgery Center, and other areas, including radiology, pulmonary, GI, and Cardiac Cath Labs.

Another immediate benefit of the new EMR Clinician Documentation is the ED Admit Report, which allows the inpatient units the ability to view information provided by the Emergency Department before transferring admitted patients to the units.