Survey: Does your facility use a paper or computer based charting for patient record

shodobe · May 3, 2003

We use a computer in the OR rooms, but still print out a permanent record to be placed in the patient's chart. Not very efficient because of the amount of paper, but seriously will a MD set in front of a terminal to look up lab values or what! I think not.Mike

Mimi2RN, ASN, RN · May 3, 2003

Do you still have hard charts when you have computer charting? All our orders are done with the computer, which generates a lot of paper, ancillaries, lists of what we have ordered. We have treatment records for each pt print up every night, even blank with just the pts ID. Lab results print up for us, and we get sheets with all lab results for each pt every night. BTW, all results are also in each pts computer chart, and the hard charts are scanned afteer D Most of this goes straight in the shredder box. We waste a lot of trees!

We have been told that computer charting wil start soon, but that was a year or two ago. I'm not looking forward to it. The computers available to us make my neck ache,........ OSHA would not be happy with the hospital! Our problem is lack of counter space......sometimes lack of floor space, too.

pwp1289 · May 3, 2003

orders still come out on paperbut soon will all be done by computer--all charting is done by computer--yes mds look in computer for results of ALL tests,xrays- they do not print out unless you hit 'print'--our nursing units have given up a patient room so now we have a 'charting' room with 3-6 computers in it--we are a teaching hosp so each 'team' of mds have their own office with 4/6 computers in them for their use--sometimes i think they are treating 'computer pts' rather than real pts!!ALL pt info is in the computer

webbiedebbie · May 3, 2003

Paper. Do not forsee computer charting for now.

RNforLongTime · May 5, 2003

At my facility, charting is mostly done via computer. I work in ICU and we use CareVue for charting. We have a computer right outside each pt room. The floors in my facility also use computers. I love it!

AHarri66, BSN, RN · May 5, 2003

We use a half-n-half system: nursing notes, flow sheets, I&O, pain assessment are all on paper; care plans, intake assessments, and MD orders are in the 'puter. Meds are in the 'puter (we have a Pyxis system), but the Medex is still hand-written paper (even though the pharmacy sends an updated med list for each pt every day.)

:confused:

jimk_rn · May 5, 2003

Our facility uses computers in 75% of the inpatient care areas, paper on the rest. If you don't like computers and get pulled to a computerized floor you may use paper. The is NO administrative support for using the system. We purchased a package deal several years ago and only initiated one of the 5 software products. By contract we are now paying ~$150.000 annually for software maintenance on 4 products we are not even using. I'm not an administrator or business person, but this does not make sense to me! They are always looking for ways to save money so they cut important positions and add a new associate VP to oversee the positions left! I would leave but hate to give up my seniority right now. I firmly believe computerization can help things run more efficiently but there must be appropriate connectivity with all systems in use. If the computers can not talk with each other, they can not share information. And in my opinion, MD's are the squeakiest wheel in the progress of computers and that is because they are so computer illiterate and do not want to be embarrased in front of their subordinants. They are so busy spending their money on their off time they don't have time to learn something new! Sorry....rambling and venting. Thanks for letting me express myself.

mamabear · May 5, 2003

We've had computer-generated med sheets for the last 18 months. We don't have to hand-copy anymore (except when we get a new admit late at night), which is good, but each patient's med sheets have to be checked for errors, and there's plenty of them. :rolleyes: This was considered a bold move forward, by the way.

There have been rumors of our switching over to computer charting, which the Luddites have been fighting tooth and nail. I'll believe it when I see it!:chuckle Some of my co-workers are still reeling from the introduction of the Pyxis system.:uhoh21: :lol2: :confused:

boggle, ASN, RN · May 6, 2003

We have had the computer generated med sheets forever. Computer charting has been around about 2 years here. It sounds like a good idea, but in reality it takes longer than the old hand charting.

The problem lies with the design of the nursing charting program. Some areas, like assessments, must be charted on completely before filing. If you have to leave the computer with the assessment 75% done you can't save it. You lose everything. How often do you we have uninterrupted time to chart?

It's cumbersome to move around from screen to screen to finally reach the area where you need to chart. Once you find the right area and begin charting, if you want to quick look back at some proir notes, you lose your unfiled current note while going through screen after screen to get to old notes.

I love being able to read the typed notes instead of guessing at handwriting, but to me the rest of the hassle of our computer charting system just isn't worth it.

And to top it off, docs don't chart on the computer. We are still stuck trying to decipher their cryptic handwritten orders and progress notes.

Ugh. They really needed nurses input bigtime in choosing and designing the computer documentation program. It could be so much better.

alwaysthere · May 7, 2003

We chart with a program that was designed for caregivers who speak minimal english..it has little pictures and you have to go through hoops to record any relevant information..I hate it

jschut, BSN, RN · May 8, 2003

We are a full paper facility.....

Wish we could go to computers.

atownsendrn · May 13, 2003

We still do paper charting. They say that computer charting will start within the year. We have many, many staff members who are resistant to change - hopefully this will force some retirement.