EHR – Let the Games Begin!

Angie Szumlinski Uncategorized

Richard VandenBerg, RN, BSN, WCC

Angie Szumlinski, NHA, RN-BC, RAC-CT, BS

The use of computers in health care settings has been present for many years, though primarily for administrative use.  Now that many providers have or are in the process of transitioning to an electronic medical record there are some important practices to keep in mind in order to keep you and your center as risk-free as possible.

The first pertains to infection control practices and involves a routine cleaning regimen.  Harmful bacteria have long been shown to be able to survive for long periods of time on equipment and other surfaces. Keyboards and mice are touched by many staff throughout a 24 hour period and each person “shares” bacteria.  This increases the risk of residents contracting infections from health care workers using shared computers to document the care provided.  Staff using shared computers should be cleaning the keyboard and mouse after each use with a germicidal that is known to effectively kill the common bugs we may encounter in the healthcare setting.  This practice combined with good hand-washing after every use of the computer or anything that could be potentially harboring dangerous organisms will decrease the risk of transmission to the residents we are caring for in our centers.

The second area to consider is basic documentation principles.  When a caregiver provides care to a resident, they must document what was done.  When an established routine cleaning regimen for computer equipment is not in place, caregivers have been observed adopting their own “practices” to reduce the risk to contaminating the equipment.  One such method observed is a nurse delegating documentation to someone else.  The belief may be that by limiting contact with the computer and mouse, the contamination risk goes down.  While the caregiver may indeed be decreasing the chances of contamination and the spread of infectious contaminants by limiting their use of the computer, they have traded one issue for another.  Basic health care documentation principles assert that if you provide the care, you document care.  There are no approved methods of delegating one’s documentation to another individual.  Whether you are still documenting via paper or computerized documentation, that record of documentation as well as the person completing the entry, is credited as being the individual who has the knowledge of what was documented and/or was the one that actually carried out that care.  That legal record and the entries related, are what is intended to provide the accurate recollection of the care provided.  Documenting in any other way opens the care giver and center to greater risk.

If you have touch screen kiosks for CNAs to document in real time on the unit, consider placing hand sanitizer stations next to each kiosk. This will encourage care givers to wash their hands immediately before and after using the shared equipment. It is also recommended that the manufacturer’s recommendations regarding cleaning equipment be adopted to prevent damage from solvents not recommended. 

Having electronic medical records is a huge investment in time and money.  Educate your staff on the importance of handling this equipment with care.  Provide the recommended cleaning products and educate on their use. Remember, document what care or services you provide; wash your hands frequently before and after contact with shared computers and equipment and clean the computer and equipment after use.  The end result will be a safer and more risk-free environment for your residents as well as yourselves.