Electronic Charting and chart reviews

  1. I work for a professional review company, reviewing hospital admissions to a set criteria. I find, when reviewing a file, electronic charting to be very difficult to read through, no changes from shift to shift, no updates or are very difficult to find. The info is very limited and tells me absolutely nothing about the patient and the condition. I also find that as an attorney, the electronic charting lives much to be desired and would be difficult for an individual to prove the care they provided to a patient, if they are involved in a lawsuit. I realize they save time, but please put more information in, concerning what the patient's condition is, what was done for them. Having to wade through several different pages with this info, instead of one is a real disadvantage for those of us that review records.
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  2. 6 Comments

  3. by   AZTRAUMANURSE
    I find it interesting that so many people are interested in what Nurses write. I also find it interesting that so many people are employed to read what Nurses write. If some of the resources spent on reviewing Nurses notes (and other documents)were spent in assisting the Nurse care for the patient, can you imagine the benefits?
    Sorry to unload on you. Just a thought.
  4. by   AZTRAUMANURSE
    Originally posted by AZTRAUMANURSE:
    I find it interesting that so many people are interested in what Nurses write. I also find it interesting that so many people are employed to read what Nurses write. If some of the resources spent on reviewing Nurses notes (and other documents)were spent in assisting the Nurse care for the patient, can you imagine the benefits?
    Sorry to unload on you. Just a thought.
  5. by   ruby mcbride
    Hello. I am one of those nurses that build electronic nursing forms. I believe what makes them so difficult to audit is multi-faceted. First, the nurses have fields that they do not have to fill out on all patients, but must be printed. So, how do you determine "did the nurse forget to fill in the blanks, or were they non-applicable?" Secondaly, each nursing area had specific forms for their use, but after we went computerized, all forms had to be blended. This was required due to the necessity of all departments having to "talk to each other" via the forms. As a result, the forms are long to include all the components required by all units. Forms that are completed on the computer are audited by one nurse, that's me - other nurses are not required to do this at this time. Paper forms (not built on the system yet) are reviewed by a team of practicing staff nurses and management. I know it appears that we spend to much time on this, but I would rather identify problems and correct them prior to being surveyed or a potential lawsuit appears - wouldn't you?
  6. by   jcebey
    Originally posted by Maylane:
    I work for a professional review company, reviewing hospital admissions to a set criteria. I find, when reviewing a file, electronic charting to be very difficult to read through, no changes from shift to shift, no updates or are very difficult to find. The info is very limited and tells me absolutely nothing about the patient and the condition. I also find that as an attorney, the electronic charting lives much to be desired and would be difficult for an individual to prove the care they provided to a patient, if they are involved in a lawsuit. I realize they save time, but please put more information in, concerning what the patient's condition is, what was done for them. Having to wade through several different pages with this info, instead of one is a real disadvantage for those of us that review records.
    Hello,
    I am one of those who build the electronic forms for computer documentation. I hear your frustration because initially the output do seem confusing for an outsider or one who does not know the system ( and there are a lot out there now). So I think it would benefit you and everyone reviewing electronic records to first get assistance from the information systems analyst to explain how the system is set up. Once you get how it is organized it is fairly easy. We build ours to make the information flow, but it doesn't seem that way the first time you see it.

  7. by   samnay
    I am a nurse who is currently using computer documentation of meds given, we are suppose to begin other documentation at some point in the future. As a staff nurse I feel this is making my job harder. I feel that a lot of times we are double documenting. This may be due to the fact that our med documentation was designed by pharmacy with little nursing input. In order to make this work you must get the staff nurse input, not managers, you need to talk to the bedside nurse, she/he will be the one using the system.

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  8. by   JenRN
    Originally posted by ruby mcbride:
    Hello. I am one of those nurses that build electronic nursing forms. I believe what makes them so difficult to audit is multi-faceted. First, the nurses have fields that they do not have to fill out on all patients, but must be printed. So, how do you determine "did the nurse forget to fill in the blanks, or were they non-applicable?" Secondaly, each nursing area had specific forms for their use, but after we went computerized, all forms had to be blended. This was required due to the necessity of all departments having to "talk to each other" via the forms. As a result, the forms are long to include all the components required by all units. Forms that are completed on the computer are audited by one nurse, that's me - other nurses are not required to do this at this time. Paper forms (not built on the system yet) are reviewed by a team of practicing staff nurses and management. I know it appears that we spend to much time on this, but I would rather identify problems and correct them prior to being surveyed or a potential lawsuit appears - wouldn't you?
    Amen!

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