It can be easy to feel like your nursing hours are taken up more and more by patient charting and paperwork. Fortunately, some changes to how you approach patient charting can help.
- Use a consistent template
Most ambulatory surgery centers will use a consistent format for patient charting. Organizing each record the same way can help ASC staff flip through to find what they are looking for more easily.
Typically, patient charts will include multiple tab dividers to separate different types of information. When you move to a digital charting format, some ambulatory software will allow you to customize sections so that your online charts can mimic what you are already doing on paper.
- No detail is too small
When looking at patient charts all day, it can be easy to feel like all the details are running together. Record as many relevant details as you can on each chart. Not only does it help the next person to review the file, but this obviously helps you later on when you see the same patient again.
The best way to get complete health histories in advance is to have patients fill out their pre-admissions documentation at-home, online themselves.
- Record in real-time, one time
Research has shown that batch documentation takes longer than recording notes in real-time. It can be hard to find the balance between documenting what the patient is saying and interacting face-to-face with the patient. Utilizing technology so that nurses can interact with the medical record at the bedside can help.
- Go digital
With our whole culture shifting toward digital storage, it only makes sense that the medical world should follow. With the numerous of patients coming through your ambulatory surgery center every day, you can quickly end up with a cluttered desk and mountains of paperwork to sort through.
Simplify your document management and storage with a digital patient chart. Digital charts are stored on a secure cloud and have customizable options, so, you can organize online charts the same way you would paper charts. In addition to doing away with a cluttered workspace and the need for filing cabinet after filing cabinet, using digital patient charting can also save you money! Get rid of pricey courier costs and stop paying off-site fees for storing and retrieving records.
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