computerized charting

  1. Don't know if this has ever been on a thread before, but need to know what you think about computerized charting. We were told a month ago that this type of documentation will be installed at our hospital very soon. It would also be mandatory for the doctors to do orders on and their H&P (would be nice since they all took chicken scratch 101) They said that laptops would be in all the patients room and the documentation would be done there. Some of the nurses didn't like the idea because they said if the patient had visitors, it would be too disruptive for them to concentrate on what they are typing

    So..........if anyone has this, how do you like it and does it save you time
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  2. Poll: computerized documentation

    • have it and like it

      60.87% 28
    • have it, don't like it

      13.04% 6
    • wish they had it

      21.74% 10
    • glad they don't have it

      4.35% 2
    46 Votes / Multiple Choice
  3. 14 Comments

  4. by   traumaRUs
    I work ER and we have EMSTAT. Is computerized charting for nurses and MDs. We love it.
  5. by   AAHZ
    At the VA we have CPRS. Its not bad at all, when you get used to it. The only prblem that i have seen, is that it is not easy to learn.
  6. by   labornurse
    we have computerized charting at our hospital. It really is faster in some respects, but as far as charting at the bed side, it really never happened even though we have computers in every room. The hospital has tried several different ways to get us to chart in the room. They have tried hand helds, demands, and other incentives and none have worked. We still enter all assessment at the desk. When the computers go down ( and believe me they will), you still have to revert back to paper charting and find the right forms. What a mess. There are privacy issues. If you have to leave and you haven't finished filling out your assessment, you have to close the computer so no one else can tamper with it and come back and reenter the assessment. There are definately privacy issues when entering assessments in the room with visitors also.
  7. by   kittyw
    I LOVE IT!!!

    My preceptorship site is 100% computerized. (outpatient clinic associated with a major hospital) Every piece of paper from the outside world that comes in is scanned and shredded. ALL forms are online. Just click on the form - no more looking for the proper forms.

    Let's say that I want to order a vaccine, follow-up appt, referral, Rx, etc. (MSN student), I can be in the patient's room and message the receptionist or nurse. By the time I'm finished with the exam and documentation, the vaccine is ready to be administered, follow-up appts are arranged, referrals are complete, and the Rx is filled out just awaiting a signature. BOOM ... it's done.

    Phone messages can be tracked - we can put the message in the basket of who needs to deal with it and can see quickly what is happening with that patient.

    All lab results appear in a separate section - I can review the labs and with a single click look at the chart. I can do this from HOME!!! (There is special security on this system.) I can get lab results back as soon as the test is completed. This allows me to follow-up with the labs the SAME DAY.

    I can graph trends with a single click. Absolutely wonderful to show the patients how their diet affects their LDL, Hgb A1c, etc.

    If a patient arrives at the ER, the ER has access to the entire chart. Talk about saving time and saving lives!!

    Sometimes the system is slow, but I've never seen it down for more than 5 minutes (there is a backup of the backup of the backup......). The day-to-day charting in the hospital is not in the computer, but all test results and follow-up notes are.

    PDAs and laptops can access the system through wireless links throughout the entire hospital and clinical sites.

    Ok - as you can tell - I love this system. I'm going to be totally spoiled when I leave.
  8. by   RNonsense
    I hate change
  9. by   RNforLongTime
    Well, in this profession, change is inevitable. I work ICU and we use the CareVue system of charting. It's great!!!

    Next month we are getting new IV pumps and soon after that new name badges.
  10. by   Tweety
    We just got it about a year ago, we still are in the process of getting our medsheets computerized. There are some bugs because we still have to chart somethings by hand.

    The most challenging part was there were a lot of baby boomers who had never touched a mouse or a computer and getting them to learn was tough. Many had a very negative attitude about beign willing to learn. But it all worked out in the end. I was one of the instructors and some people were downright cute trying to use a computer for the first time in their lives.
  11. by   Teshiee
    We have meditech. It is okay once you learn it, it becomes easier except when you get an admission or have variances you can't chart because it is not on the option list.
  12. by   MrsK1223
    I came from an office with a completely computerized system...all charting was on the comp. Loved it. Now we have some programs...we can put some of the doc's orders in but you still have to interpret what the hell they have written. I wish they would do all computerization for charting for nurses. I hate to write...especially since you do it all day. But I heard that the docs may be using handhelds to put in their orders....yippeeee
  13. by   kittyw
    Having docs type their orders into the system is wonderful! No more chicken scratch.
  14. by   Rapheal
    I love it if it is done right. In school it was user friendly but not enough computers to go around. My new place has some computer charting (admission and pharm and such) but the program is so unfriendly. So you will have to see. The issue for you is that there is a computer in every room. This will be good and bad.

    Good is because it is close and convenient. Bad in the respect that visitors may like to play with it. You will also have to make sure you are so careful in logging out because visitors and patients may be tempted to see what's in that little box. And with Hippa and all that could be a problem.
  15. by   boggle
    Has anyone used the "Care Manager' charting system?

    I've used Meditech and found it user unfriendly for nurses charting, but useful for reading lab results/ x-ray reports etc.

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