Thursday, January 29, 2009

Documentation Choices

In PALs, you can document Medications and/or Services (1) on the computer - Real Time; (2) on Paper or (3) a combination - Documentation by Exception.

(1) PALs can be setup for computer entry of Meds or Services using a mouse or touch-screen for an input device. This approach is the most costly and complex, and often, most time consuming because of the complexity, required training, and number of staff using the system.

But it is very accurate. Every service and meds is documented in real-time. If you need to know if that Med or Service was provided at 10:30 am and not at 10:45 am and you need to know it real-time, this is the approach for you. An eMAR or eSAR will print automatically.

(2) The paper form, default, will simply require to staff initial on a monthly MAR or SAR. The is the most simple and least costly approach. Supervisory staff would need to review each resident's MAR or SAR to see variations and missing services.

(3) The Combination approach, Documentation by Exception, combines the above two. Staff print a Shift Assignment sheet for both Meds and Services. During the printing process, all meds and services are automatically entered into the computer as "provided" by the staff person who logged in. Then, maybe two or three times during their shift, staff chart by exception, noting services or meds NOT GIVEN. Using this method, supervisory staff know what services were missed and eMARs and eSARs print automatically, along with variation reports.

This latter approach combines the eMAR and eSAR of #1, without the need for additional computers, input devices, or setup and maintenance of a wireless network.

With PALs you have choices.