Computer Charting: The Good and the Not-So-Good

Nurses General Nursing

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Specializes in Trauma/Burn ICU, Neuro ICU.

i'm a student working in a tele unit right now, and love computer charting. when there are new orders written, it's right there immediately. when lab results are done, they're right there. plus, my fave....when i log in, there are flags and markers to let me know that new orders and labs have been documented and are ready to see and acknowledge. that's good.

but. the nurses have commented that because everything is so quickly and easily available that some of the docs have been coming to see the patients less often - relying more on computer charting. that's not-so-good. has anyone else noticed a trend like this? there is so much information gathered by just looking at and talking with the patient, don't you think?

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Specializes in Surgical Telemetry.

We are not completely computerized at my facility yet but physicians have the ability to put in computerized orders wherever they can access a computer so if you call them for something they just put the order in and you get it. Which sometimes has it's benefit, don't have to worry about miswriting the order or mishearing the order. But on the other hand if they're in the hospital they don't come see the patient either. Although sometimes they're so busy they wouldn't be able to come see the patient anyway because they are stuck in the ER.

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Specializes in Critical Care, Education.

Very interesting - I don't think that this has been very well identified in the literature about computerization yet. I do know tha there are some other 'downsides' that have been identified

* increased errors because people either just use the 'default' information in a field rather than entering different information

* increased errors due to peculiarities with medication documentation systems - typically, it's difficult to make a late entry or put in any 'customized' information

* decreased evidence of critical thinking - people just go with the flow and click the boxes

Most of the literature has associated problems with failure to involve clinicians in the software design:banghead: Software developers don't think like nurses or docs.

But I agree - online records and automation of all those darn handoffs is really great! My 86 yo dad is a VA patient. Their charting systems and electronic infrastructure are wonderful - the clinics are super-efficient and information is always easy to obtain.

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Specializes in LTC, MDS, Education.

The family practice office I go to as a patient recently went to computerized charting. I feel like the doctor is paying more attention to the computer than me! He asks questions and enters info. Hardly any "hands-on". :crying2:

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Specializes in Cardiac, Hospice, Float pool, Med/Peds.

My new hospital is totally computerized. This is hard for me as an old time RN needs to actually see a written order to sign it off... There are NO charts... No paper at all... It is going to be good, but take sometime to get used to. The MD's are taught to put in their own orders and it is actually nice...

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