Electronic Documentation

Family Health Care, Oncology, Orthopedics, OB Health Services: Caribou, ME

Electronic Nursing Documentation

One of the most important steps in providing high quality healthcare is thorough documentation of patient information.  At Cary Medical Center, we’ve made significant investments in technology, such as electronic nursing documentation, to improve patient safety, enhance continuity of care, and ensure confidentiality.

With electronic nursing documentation, patients’ health information, including medication, allergies, past or present illnesses/injuries, and family history, is gathered and entered into a computer database upon their admission to the hospital. This is integrated with other health information the patient may have provided during a previous visit or hospital admission. Throughout the patient’s stay, nursing staff can instantly access and update health information, such as test results, new prescriptions, and changes in physical condition, right at the patient’s bedside on a computer located in the patient’s room. In conjunction with other technologies at Cary Medical Center, including computerized physician order entry, automated medication dispensing, and medication bar coding, electronic nursing documentation provides secure, up-to-the-minute information that enables staff to provide safe, personalized care much more quickly than with non-computerized systems.