Strategies to assist with real-time charting

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  1. This is a discussion on Strategies to assist with real-time charting in General Nursing Discussion, part of General Nursing ... We are moving to Epic documentation later this year with computerized physician order entry. I have...

    by Apr 10, '12
    We are moving to Epic documentation later this year with computerized physician order entry. I have been practicing real-time charting for about a month now and it is challenging. I am looking for some tips to become more successful.

    Currently we do not have computers in patient room, but 1 PC per 2 rooms outside the door. Adding computers and barcode scanners to every patient room is part of the plan for launch time.

    I am trying to tell myself that everytime I walk out of that room there is something that I need to chart, whether it be an I/O or a PRN med I just gave.

    Any tips, tricks, etc that anyone can share to make this transition more successful?
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    by DalmatiaRN Apr 10, '12 10:50 am
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  4. Apr 10, '12 by
    Fire it up when you walk in, then you can chart while you talk to the pt and do A&O. Do the physical, chart that (and you probably will chart by exception, so that's quick). You can't give meds without scanning (if you're following P&P, at least), so it has to be on then anyway. A lot of places have CNAs do the I&Os.

    You really will get used to it. Lots more room to work with on a flowsheet than in a paper chart!