Looking
to the Future:
Technology and Emergency
Medicine
Since 1992, C & M Medical Services
has been
actively pursuing the development and implementation of computerized
electronic medical records for emergency medicine. The first full
implementation of this project was deployed in November 1999 at
Kenner Regional Medical Center in Kenner, Louisiana.
That system is currently being used by
all full-time staff to generate the physician's medical record
in real time with immediate availability of a printed, legible
and complete patient record that exceeds the quality of a transcribed
record. From the outset, the electronic medical record project
has been designed to provide physicians with a user friendly,
comprehensive method to create a high quality medical record.
History of present illness, review of systems, physical exam,
differential diagnosis, final diagnosis and discharge planning
are included.
The electronic record has the ability to
cross reference patient's medications with any medications considered
in the emergency department so that interactions or adverse effects
are minimized.
The current record has built-in templates
for the most emergency department chief complaints so that a record
can be generated with a minimal number of entries. The record
is age, gender and complaint-specific.
The next phase in the evolution of the
C&M Medical Services' ED Electronic Medical Record includes
a continuation of the current model with significant additions
and improvements. This includes prompts to ensure compliance with
documentation, EMTALA, and HCFA billing requirements, as well
as collecting comprehensive data for performance improvement,
process improvement and cost analysis.
Our next phase includes the ability to
have the nursing documentation completely computerized so the
entire emergency department record will be electronic. This approach
has tremendous potential to create an environment where patients
receive high quality, consistent care with standardized treatment
plans.
Our EMR will provide both physician and
nursing staffs with the ability to generate quality records immediately
with none of the problems related to transcribed or handwritten
records. The hospital will benefit by having a cost-effective
tool to generate timely reports, ensure compliance, and support
process improvement.
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