[MEDITECH-L] WNL Except

[Maria Clause]

Is anyone using WNL and/or WNL Except in their physical assessments in PCS?
Would you mind sending screen prints of your Physicals?

We currently use "WNL" with the EMR ID "Parameters" and a text descriptor on
the query which describes what WNL means - but if ONE item is out of whack -
the user has to document the ENTIRE assessment, so we would like to move to
something like:

Neurological System ( ) WNL ( ) WNL Except

(and removing all "NORMALS" from the Physical Assessment query responses)

That way if under Neuro - everything was normal except for "Pins and
Needles" , the user could doc WNL Except and then just doc "pins and
needles" instead of the entire Neuro assessment.

Is anyone else doing it this way? And if so, would you mind sending screen
shots. We are contemplating removing ALL NORMALS from the physical
assessments.

Maria Clause

Information Services Department

Thibodaux Regional Medical Center

602 North Acadia Road

Thibodaux, LA 70301

maria....@thibodaux.com

Office (985) 435-4825

Cellular (985) 414-1485

Fax (985) 449-2508

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[Maria Clause]

Or.does anyone have any words of wisdom on doing or NOT doing it this way???

Maria Clause

Information Services Department

Thibodaux Regional Medical Center

602 North Acadia Road

Thibodaux, LA 70301

maria....@thibodaux.com

Office (985) 435-4825

Cellular (985) 414-1485

Fax (985) 449-2508

_____

[Linda Bulger]

We are Magic 5.61. We do use WNL in nursing assessments (or in some cases
WNL/WFL), but only with a "definition" in the on-line documentation. If
Nursing could produce a definition, with citation, we entered it behind the
scenes. Our queries with on-line documentation are marked with an asterisk.

Definitions of WNL may be from an approved hospital procedure, or a
reference text in common use. It was a major project to track all this down
but nurses really wanted to use WNL so they did the legwork.

The big issues around using on-line documentation this way: (1) keeping the
definitions up to date; and (2) maintaining a separate audit trail of any
changes. Be sure to have a strategy for both.

Linda Bulger, Systems Analyst
Franklin Memorial Hospital
Farmington, ME