Many different clinical disciplines collect patient information in various places — nursing assessments, pharmacist interventions and notes, and physician progress notes. This information needs to be easily accessible so that all clinicians have a complete picture of the patient’s condition when ordering medications and evaluating responses to therapy. Organize the patient record so that each discipline can easily access information gathered by all clinical departments. When using computerized documentation, set up the screens so that each discipline can access the others’ notes quickly, with the fewest possible steps.
- Use prompts in computerized records to remind clinical personnel to review documentation from other departments.
- Set up options in computerized records to enable disciplines to alert each other about specific items that need their review.
- Develop integrated reports so that clinicians can view all the information in one place when not computerized systems are not being used.