Computerized ED charting

  1. Just curious...anyone use computerized charting? How does it compare to paper charting? Are you able to chart at the bedside? What software suite do you use? Are lab and radiology test results integrated? Is it easy to use your software?
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  2. 12 Comments

  3. by   ang75
    Hey Calfax. We use computerized charting here. We use the one from GM it is called Logician. You can do anything with it-if you make it through the first week of swearing at it, hitting it, etc, etc. Radiology is integrated. The radiologists have it at home on their pc's so they can read it there and call in the middle of the noc. Now that I am used to it, I love it. You can flag drug seekers and you can even look up visits from yrs back with out going to medical records! The best perk for us it that the local Primary care offices use it as well so I can look up their office visit to see if their primary doc really did tell them to be on vicodin for all of eternity. It is fabulous and I don't know what we ever did without it.
    Oh, and we do have a pc in every pt room so yep, can still do bedside charting.

    Quote from Calfax
    Just curious...anyone use computerized charting? How does it compare to paper charting? Are you able to chart at the bedside? What software suite do you use? Are lab and radiology test results integrated? Is it easy to use your software?
  4. by   RNPATL
    Quote from Calfax
    Just curious...anyone use computerized charting? How does it compare to paper charting? Are you able to chart at the bedside? What software suite do you use? Are lab and radiology test results integrated? Is it easy to use your software?
    We use computerized charting across the entire hospital here. Actually, I love the system the VA has and think it is great. We are almost entirely paperless, which makes life pretty easy. Our consents and advance directives are scanned into the system and we are in the final stages of getting our radiology images in the system as well. Our system has all orders, consults, progress notes (which are integrated), vital signs, I&O, meds, etc on the computer. In addition, we have a secondary system (which talks to the primary system) for bar code medication administration.

    Having worked in plenty if civilian hospitals for most my nursing career .... this is a refreshing change. Some of the VA nurses do not like the system, but it works well for me. Of course, it helps if you are a computer person to begin with.

    Now, if they would only allow me to download my patient assignment onto my PDA, then it would be a 100% satisfaction rate for me.
  5. by   GDog7NYC
    Quote from Calfax
    Just curious...anyone use computerized charting? How does it compare to paper charting? Are you able to chart at the bedside? What software suite do you use? Are lab and radiology test results integrated? Is it easy to use your software?
    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!
  6. by   longjourneydream
    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!
  7. by   Altra
    I love, love, love our EDIS. I hate the certain patient scenarios when we need to chart on paper. Lab results are integrated, radiology results are not integrated into the same system but are also available on PC terminals.

    We do not have PCs in the patient rooms, but they are on the outer perimeter of the central station and our department is very compact, so the terminal is never very far away. I think I like this better than actually having the PC in the patient room -- I focus on the patient while in the room, then leave to go chart. There is an adequate number of terminals except for certain times when the department is overrun with medical residents who are trying to admit patients, then you need to be a little possessive about the terminal closest to your rooms.

    I can PM the name of the system we use, if you need it.
  8. by   danielleRN76
    We have a computerized system for documentation and labs, etc in our ER. The only problem I have is that it is not directly linked to the computerized program the inpatient units have (meditech). You can read the ER notes and such from inpatient, but cannot send, for instance the list of home meds from the ER chart to the admission form. If they are on 57 different meds, you have to retype them one at a time. and ask the pt the same questions over and over which frustrates them to no end.
  9. by   mamalle
    Im not thrilled with our system- medhost. it just doesnt flow together and takes forever to go back in chart when you have a critical patient. we also have to fill in how long the IV has been infusing, etc. also keeps track of when we put the patient in the room, time seen by Doctor, how long the patient is there from start to finish, when someone enters the room and so on.. all of our nursing orders have to be put in by the doctor and checked off by the nurse. Our labs and radiology are intergrated but the hospital wide system is still in place as we are the only ones that perform computer charting..
  10. by   Kidrn911
    We just started using Epic this summer. A lot of flaws, but they are working a few of the bugs out of it.
  11. by   littleRNthatcould
    Quote from mamalle
    Im not thrilled with our system- medhost. it just doesnt flow together and takes forever to go back in chart when you have a critical patient. we also have to fill in how long the IV has been infusing, etc. also keeps track of when we put the patient in the room, time seen by Doctor, how long the patient is there from start to finish, when someone enters the room and so on.. all of our nursing orders have to be put in by the doctor and checked off by the nurse. Our labs and radiology are intergrated but the hospital wide system is still in place as we are the only ones that perform computer charting..
    Wow, our hospital is going to medhost by the end of the year. Currently the rest of the hospital is on Meditech and the ED still uses a flow sheet for charting. We were really made to believe that it was superior system. I wasn't aware that the Docs had to input the orders, usually the docs hand the order sheet to the clerks and they input the orders. Wonder what this will mean for clerks?
  12. by   mamalle
    nope- the doctors all have to put in their own orders with medhost.That did not go over very well at all. its a great concept but too scattered for my taste. it goes from left to right and so many different places to for charting. we still write everything down in a code and go back to computer chart. when we had our orientation the girls that trained us "swore we would love using it to document during a code"..
  13. by   whatdayoftheweekisit
    Quote from danielleRN76
    We have a computerized system for documentation and labs, etc in our ER. The only problem I have is that it is not directly linked to the computerized program the inpatient units have (meditech). You can read the ER notes and such from inpatient, but cannot send, for instance the list of home meds from the ER chart to the admission form. If they are on 57 different meds, you have to retype them one at a time. and ask the pt the same questions over and over which frustrates them to no end.
    Danielle,

    We use Meditech and our ER charting system does not communicate with it either, but we have recently discovered that you can cut and paste the med list from meditech to our ER charting system and vice versa. This helps a lot as you only have to type the meds into one system and then cut and paste them into the other system. You could ask someone in Information Systems if your version of Meditech allows this or you could just try it yourself....maybe no one else has discovered it!
  14. by   alkaleidi
    Ours is CareManager (I think that's what it's called)... every room in the ED has a computer, so as or after you do something for a patient, you chart it... very clear and user-friendly... and consistent throughout the whole hospital, so what you do is visible for when you transfer a pt to whatever floor. The only paper stuff is really like the Respiratory, MI, and CVA protocols... no flow charts. You have to enter vitals into caremanager but soon (hopefully) it will be set up so that the machines that the monitors will automatically transmit info onto the computer too.

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