Computer charting-what do you think?

Nurses General Nursing

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This month my ICU will switch from paper flowsheets to computerized charting.

How many of you out there have made the switch to computer charting, and what do you think about it.

I admit I have a few reservations about it. I can quickly fill out the vitals, assessments,and other details with little effort on the flowsheet. The doctors can pick up the flowsheet and see 24 hours of details right there.

Did computerized charting make anything easier?

I've done both and I find computerized to be far easier. There's less room for subjectivity.

Of course, my job is informatics, so I'm prejudiced.

Specializes in Med/Surg and Wound Care, PACU.

i have done both, personally i like the papercharting, computercharting takes to much time, usually 30-60 min per patient, but we use medi-tech and most of it is dopple charting

nici

Specializes in L & D; Postpartum.

Hate it. It takes way more time and I know my charting is not as complete or accurate as when I could write what was in my head as opposed to canned phrases. Way too easy to miss a box. And the patient care time is cut by a lot.

Specializes in Post Anesthesia.

Almost the worst thing to happen to patient care in my career. I can never chart what I want, I double chart constantly and I can't find the information in the charting I need for all the superfluous fluff. On top of that, they seem to have a whole department devoted to adding new sections, info, scales, screening tools that have to be filled out q shift. I miss my patients!

If computerized charting is making your lives harder and taking more time you have legitimate grievances. And boy, can a lousy software package make it so.

Specializes in CICu, ICU, med-surg.

I've done both and prefer computerized charting. I think it makes information much more readily available for everyone to access; our physicians are able to pull up vitals and assessments from their offices now. I can actually chart a full assessment in our system in about 5 minutes or less. Very easy to use. Doesn't sounds like a very good system if it's taking you 30-60 minutes per assessment.

I think it's rather short sighted to say that computerized charting is the "worse thing to happen to patient care." If the system is well designed, it should improve patient care not take away from it. The problem is the design not the concept.

Todd

Specializes in Rural Health.

We have computerized charting and I have to say at first I hated it, now I kind of like it. It makes admitting a patient easier for us anyway. The admitting doc has access to the chart, the admitting unit has access to the chart. Consults have access to the chart. Everyone can see that chart now, RIGHT NOW, rather than later which seems to make the process flow easier.

Sure the doctors hated it - until they figured out they don't have to SPEAK to anyone to find out results of labs....and they can actually access their patient's charts from home via their blackberry or while sitting in their office on their computer. I don't deal with this....but I guess critical labs and notification can be sent to the blackberry as well if need be. Just another way to keep the admitting doc up to date.

It took some time though and I struggled at first. Hardest part was finding what I wanted/needed but now I can click away and it seems to make charting a bit easier.

We had to fight the fight but we won and we now have a narative section to chart when we can't find a place to chart it anywhere else. That seems to have made our life MUCH easier.

I think it depends how long you have been in the field. I am still in nursing school, and the first hospital I was at had computer charting. At the time, I thought I didnt like it and saw a few potential problems. The hospital I am at this semester has paper charts, and I find them a lot harder to find the information, and think computers are much easier to chart with. 5 people can be looking at the chart, and not bothering each other...the chart isnt missing, etc.

However, as I said before, I don't know if I'd have the same opinion if I had been in the field before...since I never really knew what it was like, I accept it and like the multidisciplinary care approach.

Specializes in Med-Surg, Psych.

I prefer paper documentation as I can easily document throughout the shift as I do tasks. With computer charting, I have to double document as I don't have time to log into the computer and document each time, so I have to take notes on assessments, pain, etc. and then document it in the computer later when I have time. It takes me about 30 min per patient to document everything in the computer. Finding out VS from CNAs is a nightmare now as they seem to think it is more important to document them in the computer than to inform RNs of abnormal VS. I spend way too much time trying to find out VS as if they aren't in the computer timely, I then have to track down the CNA who often doesn't have the paper sheet with them to inform me.

i personally like computerized charting. i have used several systems at clinicals and yes there are some bad ones out there. i like having the advan. of looking up information while the doc is looking labs up or the charge nurse is or cna is charting i &o's or V/S also, dont need to wait to see a chart. i think that paper charting is good to. my only problem with that is reading some nurses/docs hand writing. i think that it is harder for some nurses without computer knowledge. most of us on here have a good computer knowledge base, however some older nurses have never used a computer or own one, so for them, i have seen them struggle and try to work the system. however i still believe that computerized charting is a most with the way technology is heading. where i work at the moment you chart in the computer everything , the narritive is then printed on sticky paper and stuck in the chart. so it basically is a little of both.

Specializes in Med-Surg, Psych.

I typed in the wrong time average for computer documentation. It takes me an average of 20 minutes (not 30) per patient to transcribe my notes into the computer and do nurses notes. That means with 6 patients, that is 2 hours extra needed to document in the computer instead of doing paper charting - 2 hours I often don't have during regular shift hours. That does not include the extra documentation for admits. And I have no clue how much time I waste not being able to quickly find out VS like I used to with paper charting of VS.

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