i am now venting:
i am a new rn grad in the er, about 6 weeks and just getting used to our computer system.
the thing that kills me is;
they are never commenting on how i chart my physical,or psychosocial info.
but they are very concerned of how; i chart how long my iv has been running (has to be more than 31 min to get paid for it
if tx docmentation does not match dr's order, will not get paid for it.
must document that iv is running with no signs of infiltration,
or billing belives that the iv was never running in the 1st place
or there must have been problems (- a reason not to pay...).
document d/c iv at time of d/c,
so that they don't think the client went home with iv.
(another reason not to pay...)
the other day, they came up to me like i had hurt one of my patients and i was ready for the consequenses.
they said, "you sent the patient to the wrong floor".
i looked at her,
and knew i had never sent the patient to the wrong floor.
even though i sent this client to the right room,
gave report to the right nurse,
and even delivered the client to the correct room ,
my mistake was in the electronic documentation instead of on the drop down botton ,i pressed what should have been 3 center, i pressed 4 north,
what a terrible nurse i'm developing into. maybe i should have my licence revoked! (that is how they make me feel)
now i'm sorry for telling them to let me know when i'm doing something wrong in my documentation.
i feel my patient care is excellent,my newbie behavior is not too bad, because if i do not know something even if i think i do i always clarify if with someone else, (even if it may seem ignorant, not afraid of that...)
but this electronic documentation
is putting a damper on things right now....
my mistakes are not major, and in time i will get better
but what it all boils down to is how they are going to get paid..
sorry to sound so negative, this is just my point of view...
Quote from gdog7nyc
we use a system called emergisoft, and have been using it for approx 7 years now. last november, we upgraded to its newest, windows-based version and there was a lot of moaning and groaning from both the physician and nursing staff. 6 months later, it doesnt seem to be so much of a problem anymore, as everyone has gotten past the learning curve. i'll tell you, i love our documentation system. it's fast, convenient, user-friendly and provides for accurate and succinct documentation. we've tailored the system to our specific needs (i.e., built our own order sets, medication and treatment lists). radiology and the lab are interfaced into the system so results are automatically flagged and able to be read even while you're in the middle of documenting. we're slowly moving towards the goal of a paperless ed, so that will definitely be a joy! furthermore, we're able to print a multitude of reports from the system including a shift report on ones assigned patients as well as an admission report that tells me how many patients were admitted on a specific date and what the breakdown on lengths of stay were for that day. it's an awesome system that i highly recommend!