When I first arrived at Miami Childrens Hospital in the Pediatric Intensive Care Unit, Patient Notes were being written by hand. Hand written notes are very prone to error, due to the inconsistency of format, and the illegibility of most physicians handwriting.
The Pediatric Intensive Care Unit at Miami Childrens Hospital is a 16 bed unit with approximately 1,400 admissions per year. I worked closely with Teges Corporation to develop an ICU template to help improve our efficiency, implement patient safety goals, and move to an electronic medical record.
i-Rounds is a Web-based information system that provides us with the ability to view and update comprehensive patient data from a single login with any Internet-enabled device, whether a computer, laptop, or wireless PDA. At the same time, I have the ability to do research on all of my patients (in real-time) utilizing the i-Rounds Database.
Challenges within the Pediatric ICU
1. The complexity of cases is very diverse. A patient could have a wide range of problems (e.g. trauma, broken bones, respiratory distress, etc.)
2. Approximately 50 Residents rotate through the Pediatric ICU on a monthly rotation throughout the year.
3. They are limited to an 80 hour work-week.
4. Note taking must be expeditious, thorough, and accurate.
5. Prevent Medical Errors
Through our collaboration we were able to come up with a solution that allowed the physicians and caregivers to decrease the amount of time it was taking to complete the Patient Progress Notes. Teges created functionality that allowed the last Progress Note on a patient to be copied, while at the same time importing all the most recent labs and vitals information in real-time. The physicians and caregivers could then make the necessary changes to the patient record without having to re-enter information that does not normally change, such as Admission Discharge and Transfer (ADT) information, Patient History, etc. “We all have the ability to trend data, receive alerts, and access patient information at our fingertips from one location. We can also tag patients to pull data for research projects and educational compliance.”
Progress notes, procedure notes and discharge summaries used to take several hours by hand, but now take minutes. These discharges and other reports are automatically generated, which saves the caregiver substantial time.
I believe that in the future, we will have the ability to fill out progress notes and patient data utilizing voice recognition technology. We will also have the ability to give parents access to their childs medical records via the web. This would include operative images, discharge summaries, medications and other pertinent information. The greatest challenge will be how to present the data so that the patients and families can understand.
