Record Keeping in the Computer Age
As healthcare facilities purchase or develop computer systems, manufacturers offer an increased number of choices among medication monitoring programs.
From simple…
Computerized record systems range from simple to sophisticated. In the simplest systems, the computer is used as a word processor or typewriter.
…to sophisticated
In more sophisticated systems, doctors can order drugs from the pharmacy by typing the drug's name, or they can select specific drugs by searching through various listings, such as pharmacologic categories, pharmacokinetic categories, and disease-related uses.
The computer indicates whether the pharmacy has the drug. The order then goes into the pharmacy's computer for filling. The order also generates a copy of the patient's record, on which the nurse can document medication administration. In some cases, the nurse can document medication administration right on the computer with a date-and -time stamp.
Benefits bit by bit
Computer systems offer the following advantages:
When drug orders are changed, the pharmacy receives immediate notification, so drugs arrive on the unit faster.
The pharmacy's computer can immediately confirm or deny a drug's availability.
Nurses can document on MARs quickly and easily.
Nurses can see at a glance which drugs have been administered and which still must be given.
Errors from misinterpreted hand writing are eliminated.
Records can be stored electronically in addition to, or instead of, paper copies.