Paperless med-surg

TriciaJ, RN · Oct 3, 2017

This is dangerous. Not having a "brain" sheet to keep your patients information on is ridiculous. Especially if you have six patients. You could very easily give the doctor the wrong information (if they call for info and there is no computer available and perfect storm, it's an emergency). I feel this is just asking for nurses to get patients confused.
We are "paperless" and have EHR's at the hospital I work at. But we still print patient labels (for specimens), and a face sheet (for EMS should the patient need transferring).

OMG a light just went on for me. Anybody remember the thread by the engineer who was going to invent a way for us not to get confused about which patient was in which room? Is this what he was talking about? Nurses not even being allowed to carry a brain sheet? Is he going to invent a marvelous high-tech brain sheet replacement?

Apples&Oranges · Oct 3, 2017

We were told this when we switched over to EPIC. Absolutely no paper EVER. We had to work solely from the task list. No brain, no notes, nothing.

Guess what? Two years later, I have my self made assessment sheet on every patient, and no paper policeman has ever confronted me about it. They'll pry my paper report sheet and checklists from my cold, dead claws.

Don't stress about it.

mrsboots87 · Oct 3, 2017

I agree with whoever is trying to impliment an absolutely no paper system is not a clinician. This is incredibly dangerous. I'm sure there are nurses who can go a whole shift without writing anything down and that's great. But the vast majority of nurses rely on writing down notes. Most EHRs don't have EVERYTHING that needs to be done in the task list. No teminder on what needs to be charted when. Half the time procedures aren't in the schedule and if you don't right it down, it's easy to not know when your patient will be off unit. The Pyxis never has every med correct under each time of day. I could go on. Paperless is just asking for errors and dangerous patient care.

TriciaJ, RN · Oct 3, 2017

I agree with whoever is trying to impliment an absolutely no paper system is not a clinician. This is incredibly dangerous. I'm sure there are nurses who can go a whole shift without writing anything down and that's great. But the vast majority of nurses rely on writing down notes. Most EHRs don't have EVERYTHING that needs to be done in the task list. No teminder on what needs to be charted when. Half the time procedures aren't in the schedule and if you don't right it down, it's easy to not know when your patient will be off unit. The Pyxis never has every med correct under each time of day. I could go on. Paperless is just asking for errors and dangerous patient care.

Why don't they just stick to their ridiculous scripting and other stupidities and leave nursing to nurses?

JKL33 · Oct 3, 2017

Speaking of scripting...

I had a humorous little thought when I read this yesterday, but trying to be mature and all, I didn't post it. Now that I see the facility is, in fact, trying to prohibit a "brain sheet", here's my immature idea:

OP, design a fancy letterhead that says this: "Is there anything I can do to help make you comfortable? I have the time!"

Use a nice frilly, lovey-dovey font and all that.

Print these out to use as your brain sheet, making sure to write on the "back side" and keep it folded with the letterhead on the outside. When you get caught with the contraband (aka piece of paper), simply explain that you like to carry this with you, since it is your priority to provide top-notch customer service at all times.

JKL33 · Oct 3, 2017

changed my mind :)

allnurses Guide · Oct 3, 2017

Our facility recent changed EHRs, and we're being told that soon we will not be allowed to have any papers for our patients. The previous system provided multiple sheets per patient with the orders printed out, and I found it very cumbersome to navigate. I have my own sheet and I can cover my 7-8 patients on 2 pieces of paper. The EHR has a report page that we are told we will reference during bedside report, but to me that is very difficult to synthesize into an informative report. And I use my paper as a checklist throughout the shift, to remind myself when I've checked patient #1's IV flushed, and cleared the pump volume for patient #4, done my education and care plan on everyone, etc. Are there other med-surg nurses out there that have gone totally paperless? Any tips on how to do it? I really think that some of us are just list/checkbox people and to demand that we not use them, just to save 2 pieces of paper, seems like focusing on the wrong aspects of our job. Ensuring that I'm able to do my job thoroughly and safely, even if I need some paper, doesn't seem that awful to me. I'm not resistant to change for the sake of being resistant, and I'm definitely willing to give it a shot, I could just use to tips. (Or others with experience that it did or didn't work out). Thanks!

We went paperless this year and the facility no longer provides us with paper report sheet. It is the expectation that we will give report from the flow sheets and information on the computer. There's nothing to keep you from having your own notes for personal reference though - I have a spiral notebook that I keep stuff in then just tear out the page and drop it in the shredder on my way out. Still learning to do report off the computer isn't hard and once I let down my mental block's and I'm a crusty old bat it really is easier than I would have thought.

You'll get it

Hppy