Paperless documentation in outpatient care - How does it work?

The transition to more digitality in everyday care takes creativity and patience. The mobile care service of Protestant Altenhilfe Westpfalz (PAW) is already in the middle of the journey to paperless care documentation. Lara Lange, a registered nurse at the Donnersberg mobile care service, reports on her experiences. 

Why did you decide to digitize the nursing documentation? 

One of the main reasons for digitizing our outpatient care documentation was our steadily growing size and the associated file storage. Since we have few storage options, it was the most sensible solution for us to digitize files.  

How did you organize your documentation before going digital? 

We had documents from our clients stored in two places. Firstly, in a folder directly at the patient's site, where documents such as report sheets, SIS, action plans, copies of prescriptions, etc. were stored, and secondly, analogous to the folder at the client's site, there was a file in the office, where all outdated documents were stored.

In your experience, what are important prerequisites on the way to digitizing documentation?

In order to start the digitization process, a program that supports digital documentation is needed. In our case, we work with Vivendi NG in the office and Vivendi mobile in the tours. What is also needed is time. Digitization takes an enormous amount of time and does not happen overnight. 

What were the stages of your journey? 

Our first step toward digitization had little to do with Vivendi. For years, we have been digitizing the client files of departed customers and storing them on a server. 

The introduction of Vivendi NG and Mobil paved the way for the expansion of digital documentation. We began the first step by digitizing client files from current customers by scanning each file from the office individually and storing them in the file repository in Vivendi NG. 

In the next step, we first carried out double documentation, once on our paper report sheets and secondly directly in Vivendi mobile. This allowed our employees to get used to doing their documentation in mobile. We did this for about 8 weeks, after which we collected all the report sheets from the files and scanned them again. Now it was only possible to document a nursing report digitally. 

In the next step, vital signs were then recorded on the move; here, too, we kept double documentation at the beginning and slowly phased it out. In the area of vital signs, too, we now only document digitally. 

In your experience, where does digitization already work well and where can it still be expanded?

It must be said that not all documentation is yet done directly digitally. In the tours, almost all documentation is done digitally. One exception is our BTM control, as this is not yet supported digitally. Service records also still have to be filled out in paper form. But here, too, some health insurance companies are already testing the digital signature of the patient. It is therefore foreseeable that these will also soon be issued only digitally. 

In the office, on the other hand, a lot of work is still done on paper, which is scanned after processing and entered into the file repository. We are working on recording new clients digitally on site. This is done via a tablet and the Vivendi mobile app. Nursing rounds and consultation forms are still processed exclusively on paper. 

What obstacles have you and your team encountered on the way to paperless documentation and how do you deal with them?

Some processes have to be converted in order to implement digitization. These conversions were not always accompanied by jubilation and joy. Many employees were skeptical at first. Many didn't know whether they would be able to document properly with the cell phones, since their understanding of technology is not great. However, we were able to convince everyone to at least give it a try. And in retrospect, they all manage much better than before. Of course, a lot of technology also brings many problems for people who have not grown up with technology. That's why we have set up a Vivendi Mobil representative to help employees with questions and problems. 

What has changed since you started using voize speech recognition? 

Currently, our documentation process is as follows: Our employees document vital signs and report entries digitally via mobile device during the tour. Office staff document phone calls digitally via computer. Prescriptions, authorizations, correspondence with insurance companies or relatives and all other important documents in paper form, are scanned and filed directly in the patient file in Vivendi. SIS and action planning are either written together with the documentation officer in the office on the PC or by the employee on the mobile device. Wound documentation is also recorded either directly via the mobile device or via the computer. Evaluations are also carried out by the documentation officer in the office.
Now, however, this process has been simplified and made easier, as typing on the small mobile devices can sometimes be very tedious and take up more time. We started using voize voice recognition this month. This way, reports, vital signs, SIS and action planning can be done in a simplified way as voice input. We are really excited about voize. We save a lot of time with voice input and our employees no longer have to type their fingers to the bone.

What would you like to pass on to others in terms of digitization?

In conclusion, I can only say that it was worth it and that everyone is satisfied with this development. We would go down the same digitalization path again at any time. Digitization is a development that you can't hide from, our world is becoming increasingly digital and we as a company have to keep up. The sooner you recognize this, the easier it will be in the end. I can only urge all mobile services, but also inpatient facilities, to start digitizing files as early as possible. And here I don't just mean patient and resident files, but also employee files.

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