Shrinking a patient's chart: Building the next step to a complete
Electronic Medical Record PCS (Patient Care System)

Less paper and more efficient, readily available documentation for patient charts. Those are some of the objectives of an electronic system accessible by caregivers throughout the Pen Bay Healthcare system.

This patient care system is a module from MEDITECH, PBMC's electronic medical records (EMR) vendor. A team of nurses at PBMC, called the PCS Core Team, is spearheading this effort. In April, members of the team attended a four-day system orientation at MEDITECH in Canton, Mass. PCS stands for Patient Care System.

The PCS module is designed as a multidisciplinary system in which Nursing, Respiratory Therapy, Physical Therapy, Occupational Therapy, Speech & Hearing, and other services will document patient assessments and care delivery electronically. Some outpatient services will also take advantage of computer-based documenting. Point-of-care devices (computers that are handheld or on carts) will enable the staff to document the care they provide in patient rooms in real time, as they provide it.

As PCS is implemented, the traditional paper chart will dramatically shrink.

"Over the past year we have stopped printing many documents that have traditionally been in the paper record and now reside in the computer," said Kevin Varga, RN, a member of the PCS Core Team. "Those using PCS will find a streamlined process. Being able to document at the bedside, and not having to spend time to find the chart or clipboard, will allow for the timely documentation of care. This will allow caregivers to have more time to spend at the bedside."

Varga continued: "And because documentation will be computer-based, it will be available for review immediately by those that need it. Physicians and other care providers will be able to view the patient’s record from any computer connected to the PBH network."

"The immediate availability of current patient data will help physicians and caregivers provide a higher efficacy of care to our community," he said.

PCS Core Team. Front row, from left: Patricia Bendtson, RN;
Susan McBean, RN; Kevin Varga, RN; Ann-Marie Rintz, RN.
Back row, from left: Loree Niola, RRT, Clinical Analyst;
Torey Frederick, RN; Doug Barnett, RN; Kay Allan, RN;
Tom Woodman, RN; Carol Heyer, RN. CCRN.
Not pictured: Rebecca Greene MT (ASCP) BB, Clinical Analyst.