For those of you who use electronic documentation, is there a time/instance when you stay on paper, ie for really unstable patients? In our organization, we are new to E documentation, and it's been decided Trauma and Resuscitation patients will stay on paper, but we are trying to come up with criteria for patients who are unstable who need to stay on paper...
also, do you have special forms for these type of patients or do you just go to downtime procedures?
Our traumas and code blues are on paper. Everything else is in an EMR. We have specific forms for each. Where trauma is concerned, there is specific data that must be captured if you are a leveled trauma center or are seeking to be verified; the information goes into your trauma registry (database) and is reported both nationally and to the state, so it really can't just be free-charted.
Everything is electronic where I work. We don't even have any physical chart binders in the ED.
There is an electronic form for charting codes so no need to scan meds and such, most people write it down and then do it on the computer later, but I have seen a few doing "live" charting. I tried once and failed miserably, but was new to the ER at the time.
For Trauma, there is a trauma template in the EMR is where everything is done. we do have a "cheat sheet" form that has the specifics needed, but they still must be put in the computer. As said, there are specifics that need to be captured for designation levels and such, and that info is much easier to get from an EMR.
It all depends on the EMR your hospital uses. There are some out there that allow you to chart traumas, codes, procedural sedation etc easily. Talk to the IT or informatics people (and the people holding the purse strings) to find out what you can do to chart everything electronically. I've worked at a few facilities, which have all done things differently, and it seems to be easier in the long run when you can chart everything electronically.
thanks spongecake! i'm on the team implementing an EMR in the emergency dept... it's been mandated by the gov't that we keep our traumas and arrests on paper... but i agree, i want everything else to be electronic.
if you are caring for an unstable patient and multiple nurses are providing simultaneous care, how do you chart that? one recorder? does everyone "sign" somehow? or does everyone chart everything they've done after the fact?
My facility does codes on paper - but the instant you get a pulse back, you're off paper and on computer charting
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