Documentation

  1. I am seeking opinions on Emergency Department Documentation systems of all types. I value your opinions on what works & what does not work. Many companies are selling "templates". Do you use those or create your own? Those of you who are using "paperless" systems, how well does that work? And what type of portable computer do you use? What "paperless"system are you using.
    I am hoping for lots of input, because I know everyone must document. Thanks
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  2. 11 Comments

  3. by   RNFROG3
    We use the GE Centricity ED Tracker and willbe going to computer documentation eventually. Right now- when it works- the system tracks our patients, tells us where they are, if they've been x-rayed and if their labs are completed. It also discharges them from the hospital. As for paper documentaion we use the DAR method supposedly. (Data, Action, Response) Most still write out things in narrative form. Our form also has a spot for focas where you can give a blurb about what your note is about- say med/iv - where a med was administered and an IV started. Unfortunetly there are those who totally disregard that and so you have to read thru all of there notes to find out what has been done so far. Keep fingers crossed for us mid Indiana folk JCAHO comes the 8th!
  4. by   ERNurse752
    Originally posted by RNFROG3
    Keep fingers crossed for us mid Indiana folk JCAHO comes the 8th!
    *Music from Jaws and Psycho playing in the background...*
  5. by   dkuell
    We have been using Wellsoft for two years & love it! To date we use the tracking board, nursing documentation, prescription writer, discharge instructions, Lab & Rad results & physician order entry. The only thing left is physician documentation. We developed our own templates & can add more at any time. It actually makes documentation easier because you aren't faced with an empty page that you have to make sure to fill in completely & accurately, you just fill in the blanks but can also free text. The only complaints I ever hear are those times when the system comes down for upgrades. These only last about five minutes so we are a happy lot. None of us would ever want to go back to paper! This is a really easy system to use.
  6. by   tony summers
    We use a combination of pre-printed standardised forms for things like head-injuries/eye problems/hand injuries and those that present with asthma. These cut down on the amount of other paperwork we have to produce. No matter what when the computer system fails we still revert to the old fashion paper system.

    Trouble is when the computers come back on we hae to enter everything back on to the computer system
  7. by   OzNurse69
    We use Cerner - fine, as far as a computer system goes - BUT - until the pt has been put into the puter (name, ad, dob etc) we can't make any records - so the pts that come in via amb. have paper docs unless they have been there before - AND - during a full-on resus, the computer goes out the window, & the notes get done on paper then entered into the computer later. Don't think any system is going to get around that though....
  8. by   dkuell
    With Wellsoft we are able to enter the pt via the call-in (i.e., 174 enroute) & then document. We use the computer for all codes & traumas. It is honestly easier than a piece of paper because you don't have to keep up with it. You just log in at any work station & enter your data.

    The big pluses are no more searching for the chart & more than one person can work on the record simultaneously.

    This system was developed & is administrated by an ED physician who knows our problems & speaks our language which makes it very easy to make changes and additions.

    Both nurses & EPs really like the system. I have also been impressed at how rapidly new people take to it. I am finding more who have used other systems but say this is by far the easiest.
  9. by   Sarah, RNBScN
    Wellsoft ?? please provide more information.
    Would appreciate it.
  10. by   dkuell
    We have been live with Wellsoft for two years, saw 51,000 last year & are on track for 53,000 this year. We are a rural receiving hospital but do not an official trauma designation. We are located in a retirement, resort area & cardiology is our most active speciality.

    Started with patient tracking, discharge instructions and prescription writer. Next we added nursing documentation including triage, then physician order entry & testing results. Our PA's in Fast Track do 100% documentation via Wellsoft.

    Prior to system purchase the medical director & I made a committment to 100% usage. I have stuck to that but the docs haven't. I lost three staff members who were afraid of trying but they have returned. The docs have been using telephone dictation for 10 years & don't want to give it up. They are currently looking at voice recognition dictation for documentation. Their dictation is so good if it wasn't for the cost reduction I wouldn't try to change.

    The benefits are many. Templates (customized with our input) improved the quality of documentation, triage, code, restraints, conscious sedation, discharge are a few. You can use required fields to enhance compliance. We no longer hunt for charts, you can access the record from any work station in any area of the department & more than one person can work on it at any given time. Our docs do their own d/c instructions & enter all their orders. Efficiency is increased because when an order is entered the board is instantly flagged for the entity that has to complete it (i.e., nurse, secretary, ancillary department). Attendings picked up the system instantly because of ease & efficiency of use.

    The reports you can get from the system are great. We study just about everything & use the data to improve our flow. Our visits have gone up by 6,000 since installing Wellsoft & we have added very few FTE's (& they have been meeter/greeters & NA's).

    Nurses & docs who join our staff from other hospitals using other systems have nothing but good to say about Wellsoft. They find it very easy to learn & use.

    Wellsoft is a delight to do business with. They are very supportive, honest, & try everything to help make things the way they work best for the individual hospital. And they never sell vaporware. If they can't do it they are up front about it. Of course they go back & try to find a solution but you always know where you stand.

    Even our ancillary departments have access to the system so they can look up patients & we don't have to send charts anymore. PI is hooked in as is the hospital Patient Rep./Risk Management.

    Answering patient complaints is much easier because when they call I can instantly pull up the chart w/o ever leaving my desk & when the person says it took 2 hrs to see me I can respond I know it seemed like that but I have your chart in front of me & it was only 10 minutes (my favorite use).

    If you have other questions let me know.
  11. by   gardengal1
    We have T-system which is extremely user friends and is specifically for the ED. It takes about a total of 10 minutes to learn how to use this system. BUT, our hospital is sick of Meditech which is what every other department has and we are now going to Cerner in 2011! We all have reservations about going from an easy to use system to one that is more complicated to learn.
  12. by   murphyle
    We've got Epic oneChart in our EC, which runs everything - EMR, CPOE, eMAR, patient tracking, the works. Floors have Epic for charting but they've not yet gone live on CPOE. (We're the test bed for a lot of the Epic functionality since, to be quite frank, we beat the heck out of documentation systems. There's always some new function in emergency that no one's thought of to date.)

    We're fairly happy with it so far. A few of the less computer-literate nurses still whine, but they're becoming less with time and experience. Docs are increasingly onboard with CPOE (more so since we hired scribes to chart for them - I have my own thoughts on that, but oh well). Ambulances get put into Epic as soon as we get the radio calls, so we can start charting right from the get-go. The only thing we use paper documentation for anymore is resus, and that information does eventually find its way into Epic after we're done. Quite honestly, the biggest pain in all our necks these days is re-copying everything out of Epic onto paper orders for the floor!

    The only issue I see with the system is scalability. We're a three-hospital metropolitan system with about 1700 beds total, and Epic works fine for us. Problem is, it runs across a Citrix server farm, which is notorious for getting increasingly unstable with increasing user loads. I wouldn't dare try it with a big university system or a regional conglomerate.
  13. by   LittleBittRN
    We use Tsystem EV and it is great! Very easy to use and learn. It has the CPOE function so the doctors place all their own orders in minutes after seeing the patient- this has allowed us to free up our techs to work on the floor instead of sitting at the desk putting in manual orders. We only have one tech now on the desk that places calls and puts in admissions. The nurses love it.
    Hope this helps

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