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?
Apr 10, '12
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!