The patient chart is an analytical tool that enables clinicians to get an overview of all the patient’s essential information on one screen. It is the final step in the process of the digital transformation of a hospital because the digitalisation of the basic clinical processes, where the data is generated, is essential. Why? Because doctors spend over 90 % of their time behind a computer looking at the patient chart.
Paper patient charts have always been the centre of collecting and viewing patient data during a hospital stay. It is an indispensable tool for doctors and nurses during morning rounds, consultations, and multidisciplinary boards. By looking at the patient chart, together with performing a physical examination, clinicians can get a comprehensive understanding of the patient’s current state.
The patient chart provides doctors with information needed to plan further treatment, manage discharge or adjust current treatment plans. One of the most important features of the patient chart is the ability to view and track patient data over time, allowing doctors to make better-informed decisions about the patient’s future medical interventions.
The patient chart provides all the necessary data
Digital transformation of hospital wards changes clinical practice workflow. It also affects the patient chart which is one of the most important modules but also one of the last ones to be digitised. An electronic patient chart, as did the paper one, enables clinicians to track the patient’s vital signs, laboratory, radiology, and microbiology results over time.
The real added value of an electronic patient chart is how customisable it is. In an electronic patient chart, clinicians can choose to track as many vital signs as they want to. They can choose to see various custom parameters like hunger level, urine output, fluid balance, or pain severity. They can pull their preferred laboratory results and review them along with the patient’s other health data. They can choose to flag abnormal results or plot the data to see the changes visually in a graph. All that is customisable, and clinicians can build their custom views for themselves or for their department. The level of complexity and patient data needed to be reviewed on a daily basis varies greatly among different departments and medical specialties. Surgical departments have different needs than medical departments, and even doctors on internal medicine departments have different preferences for displaying vital signs, laboratory results, and other patient health data on a patient chart, depending on their specialities.
Digitising medication management is one of the crucial steps
Another important part of the patient chart is the medication segment. Doctors can see the changes to the patient’s vital signs and other results in correlation to adjustments to the patient’s prescribed medications or the changes of medications in correlation to the changes in the patient’s vital signs, laboratory results, and other health data. In an electronic patient chart, the changes to the patient’s medications are easily identifiable. New medications added, changes in dosing, or frequency made to the existing therapies are highlighted at a level of prescription and on a daily administration level. Doctors can interpret those changes in regard to the patient’s vital signs, laboratory results, or radiology findings on a daily level, but can also choose to evaluate them in a shorter time period, depending on the preferred time view.
The digitalisation of medication management is one of the crucial steps. An electronic medication management system supports the process of prescribing, administration, and pharmacist’s review. It enables medication-related workflows in simple and complex clinical environments. The changes in prescriptions and administration need to be easily seen on the electronic patient chart. Digitalisation of other modules, such as laboratory, microbiology, and radiology systems, is also necessary, along with the daily doctor and nurse observations.
Electronic patient charts are one of the most important and commonly used digital tools in hospitals. According to some research, doctors spend over 90 % of their time behind a computer looking at this view, as it enables them to see all of the patient’s important health data over the chosen period on a single screen. Unnecessary or too much information discourages clinicians from using this digital tool, which is why the ability to customise an electronic patient chart to individual or department needs is very important.
