Documenting patient height and weight in the EMR

Did you know that, today, we may document a patient’s weight multiple times in a multitude of different places during a patient’s admission? In the EMR, measured weight will be documented once and viewed centrally by all clinicians treating the patient.

The EMR team had a productive week last week completing close to 65 workshops. The team is extremely grateful for the close involvement of all our Subject Matter Experts and Accountable Leaders, without whom the workshops would not be possible. You may be wondering what actually happens in one of these EMR workshops and, while each workshop is very different, we will take you to one which validated workflows and design decisions regarding height and weight documentation in the EMR…

Each workshop is different, ranging from introducing order sets, discharge workflows, documentation, to validating complex medications on the EMR system. Last week, the team had the opportunity to meet with respective SMEs and Accountable Leaders to validate and design decisions regarding patient height and weight documentation in the EMR.

Before the session, our analysts consulted widely with our clinicians from different disciplines and specialties to understand Northern Health’s current state. They then designed the workflow and functionalities in a test environment of the EMR (as known as a ‘domain’). In this particular workshop, there were representatives from nursing, medical, allied health and pharmacy, with workflow requested to be signed off by our nursing Accountable Leaders, Deborah Zilm and Lucia Bento.

The session started with Isah Rosal, EMR Clinical Documentation Analyst, documenting in the EMR as a nurse by using CareCompass, which is a nursing worklist. From the CareCompass, clinicians can easily see the information relating to the patient, their care team, length of stay, activities with tasks for nurses to address. Isah demonstrated how the patient’s measured weight will be documented, which then will be displayed in a highly visible blue banner bar at the top of the screen.

Isah demonstrating EMR PowerChart to workshop participants

Clinicians will also be able to view past documented weights from the patient’s previous visits (known as encounters) when navigating the blue banner bar.

During the session, Jessica Hart, EMR Medications Lead, logged in as a Doctor to demonstrate the medical workflow of placing a medication order for the same test patient. With our patients’ best interest in mind, if doctors try to place a weight-based medication for paediatric patients without a documented weight, a dosage calculator, as well as alerts may pop up to notify our clinicians.

The session ended with Isah from the nursing perspective to confirm the automatic rule that will task the nurses to re-weigh the patient every 7 days (from admission), which any weight changes will be automatically updated in the blue banner bar.

The workflow was validated by the Accountable Leaders. Deborah Zilm, Accreditation Officer (Chair of Standard 6) commented she ‘loves that nurses will only need to document weight and height in one place in the EMR’.