Wednesday, May 11, 2011

Transition to e-Documentation

The NIH Clinical Center’s ICU is transitioning to an electronic documentation system containing patient medical records. The system is replacing a hard copy paper flow sheet that has been used in the ICU for decades, said Dr. David Henderson, Clinical Center Deputy Director for Clinical Care.

The new system will be accessible through the Clinical Research Information System (CRIS) and will mimic the format of the flow charts while streamlining the documentation in a single location. The new patient-care technology records will contain virtually every electronic observation made of a patient’s condition and vital signs.

Henderson reports that in addition to increasing efficiency and patient safety in the ICU, the system will also allow investigators access to important information that will benefit clinical research initiatives and enable researchers to easily access patient information that is collected in the ICU.

Ryan Kennedy, an information technology project manager for the Department of Clinical Research Informatics, coordinated and implemented this customized electronic documentation initiative. According to Kennedy, the system will make it easier for nurses to document patient information while displaying the information in an easier way for the physician group.