Charting

LovebugLPN · Mar 10, 2007

I worked in a doctors office that had computer charting. I hated it because one of the MAs went in to the chart and deleted information and left my signature after it. If the patient hadn't called back to add more information I would not have known. I went into the history of the document and saw who it was. I called her up and explained that if she had anything to add that she would have to take a seperate note but that she could not add her own info and leave my signature. I then went to my supervisor and expalined the problem. She asked if the MA had fixed the problem and I said she did. That was all that was done. It made me very nervous from then on. Who knows how many times this had been done by her or anyone else. I am not sure what would happen if something had happened to the patient. I have no proof in a court of law what she had changed or added. I like paper charting much better.:uhoh21:

Bluehair · Mar 10, 2007

Is it just me...or does it seem as though computer charting for nurses is stuck in the stone age?!?! I mean, this is the age of technology, correct? And we seem to have a surplus of computer engineers/programmers, etc. in our jobforce. I just don't understand why healthcare computer charting, especially for nurses, remains so complicated....not user friendly in the least.
I worked at every hospital system, with the exception of the VA, in my Metro Area while doing clinicals during school. Each hospital had a differenct charting system...each with its own quirks and pitfalls. I consider my hospital's systems one of the best, yet it is riddled with flaws. I don't understand this. It seems like sooo much money could be made from designing a user-friendly charting system, especially if it was linked through multiple hospital systems where different facilities in different networks could share information.
Is there a specific area of nursing that focuses on this type of technology? I floated to our ER today and they have an AMAZING charting and tracking system, but it was designed specifically for the ER...it wouldn't work for the floors. In fact, we can't even access their system because we use a totally different system.
I feel like computer charting, in general, could be improved by leaps and bounds.

I agree! This is the first hospital I have worked at where they did all their charting in the computer. The system is called Meditech and it's a pain. Not intuitive at all! I'm used to it now, but it is very time consuming to go through each intervention and document everything that is required. I do miss the days of a bedside flow sheet. I know in a lot of ways computer charting can be a big help in certain aspects - storage of charts (tho locally they print the whole mess out and keep that as well as store the electronic info off site as well as on-site), capturing of data for chart audits/data required to report to Medicare, etc.; you can review a lot of info from anywhere in the hospital which can help various MD's/Nurses/case managers/risk managers, etc.etc.etc.

I'm with you - there has to be a more efficient charting system. 'They' get so worried about security issues it takes forever to log on and get into the patient chart. God forbid you get called away from the computer terminal for just a minute and leave it open where someone else can see that Mrs. Jones is ..... in the hospital! (Gasp!). Quick, call HIPPA! There doesn't seem to be enough hours in the day to get my patient care done, especially in ICU when they are so sick. Then I have to try and get it all charted later in the shift, and not forget important details. There most certainly has to be a better way, but I bet it's not cheap!