Survey: Does your facility use a paper or computer based charting for patient record - page 3
Here are the results of last months survey question Does your facility use a paper or computer based charting for patient record : Please feel free to read and post any comments that you... Read More
May 15, '03We have what we call Cardex's where we write daily about the old people at the home. But it takes so long to read it as this has to be done EVERYDAY morning and afternoon and Night for Changeover staff. Some days there are like 20 cards to read it is crazy.
May 19, '03Ok I admit to being computer stupid. Our facility is paper but what I was wondering is how would you sign your nurses notes on the computer or your initials in the MAR. Just curious we are currently having a budget problem so I dont see changing to computers any time soon. Especially since we have been in a budget crunch since I started there two yrs ago.
May 19, '03hi angelbear, if they were logging on to the computer either with a password or a proximity care or swipe card this would be like their signature. that is why they should never allow use of your password with a computer system. you don't know who would use it.
May 19, '03Homesick honey, we cerner in our facility. I think it is a good product but it can't do everything. The problem we have is ourIS dept doesn't like it so we have a hard time integrating it into our nainframe. It also "goes down" for maintanence(sp) on Sun from 3-6am. Guess who has to chart assessments, activity, treatments ect on 10pts on Sun? Yep, thats my shift. Once in a while, the computers do not come back up at 6 then its a mad scramble to chart on paper so we can leave on time (overtime is a no-no) I like computer charting for the most part its the outages that drive me crazy!
May 20, '03Thanks for that, darn mom128.were you around when they went from paper to computer? i was wondering if it was well supported by the suppliers. i am worried that it will be a case of get on with it and my colleagues are going to have a hard time. any more information you can give would be great.
May 22, '03currently using paper....keep getting told the computers are coming....i have been hearing of some problems with computerized charting. Not sure now if I am looking forward to it as much as I was previously.
May 27, '03At the moment iam goin for my clinical practice in one of the resthomes and i havent seen any computer based charting for patient record all i have seen is that every patient in the resthome has a file where they have all the information about them in the file in a hard copy.
But iam pretty sure that there are quite a number of Nurses who use Computers to chart their patient record in the hospitals.
I say computers save a huge amount of time for busy nurses.
May 28, '03It's a mix here.
At the main hospital where I was until Feb., we still charted on paper. But labs, test results, Xrays, H&P, etc., are on computer. A paper copy of same is on the chart. We also enter VS, I&O onto computer at the end of the shift. (That info is also on the paper chart.)
In Home Health, where I am now (same hospital), we have laptop computers for OASIS, and we all fill out our time sheets on computer. Two of the RN's have "gone live", meaning they do *all* their charting for daily visits as well as everything else on computer. We will all be going "live" by the end of the year. The two RN already there are helping streamline the program, sorta "beta-testing" it before mass comsumotion.
Getting back to the hospital itself: I see several of you mention MDs being resistant to the use of computers. We had a hard time getting ours to look up results for themselves also. But finally Nursing Admin mad a rule that we WERE NOT ALLOWED to look up results for the doc. They all are able to take the same course *we* took when we were hired in that taught us how to use the programs. And they are all able to have free hook-up from the hospital to their homes to be able to look up values and results at their homes, then call in with orders if need be. We were told by Admin to tell Dr. Ihatebeingadocandihateyoutoo, "It is not my job to do *your* job." Actually, I have never had a problem.....even the most resistent MD finally "got it" and calls up his own results (while we all hear him cursing out loud - hee hee)
May 30, '03Use paper only at my own facility and a mix of both where I'm doing clinical. Have to say I don't like the computer system. Even the IT department says it's outdated and clunky. I have found that it doubles the amount of work b/c most charting can be found in both places.
Jun 4, '03We have a new printed Kardex at the start of every shift, YAY, no more erased Kardex to the point of not being able to read most recent penciled in orders. Med charting is computerized too. All the rest is still on paper. Save a tree, will ya!
Jun 4, '03We've been using a version of computerized record keeping (notes and orders) since November '98, if I recall correctly.
We'd always done odd little tasks in the computer - order and view lab results, request diets, etc, but then the Computerized Partient Record System (CPRS) was introduced and bit by bit it has 'replaced' the paper chart except for backup materials and those things we haven't been able to incorporate just yet. For example, you can order an EKG or CT in CPRS, but you can't 'view' the result there, only read the dictated report of the reviewer.
For charting, I love CPRS. Opening a patient's chart lets you see at glance all active meds, last vitals, recent labs, allergies, warnings such as DNRs/LWs, MD's name .... A tab system lets you move to specific areas to review labs, notes, consults, etc.
Entering a progress note is simple and you can make multiple addendums to them. The notes are searchable by author or title in CPRS, or you can enter our 'administrative' software to make a general search across patients, including a search for specific terms contained in the body of the note.
For the most part orders are entered and transmitted electronically to the department that needs to act on them without requiring a ward manager or nurse to take additional steps. (Some things still have to be scheduled, UGIs, PCs) Order Sets make some things quite easy because common things are pre-formatted and all you do is select them. You can order daily labs this way, or review/select from the standard AHA orders for ACS.
Plus, as someone else mentioned, no more puzzling over handwriting.
Our meds are computerized as well, using a Bar Code Medication Administration system (BCMA). Our unit still uses paper med sheets as a backup and because we like them.
We also tend to use flow charts for the bedside because it does take time to log in when all you want to do is glance to see what your BP was an hour ago..
We still keep a paper Medical Record available. Documents that have a duplicate in the electronic record are supposed to be removed from the paper Medical Record after 3 years. EKGs are kept regardless of time frame until they find a patch that'll let us view them on the PC.
We're not 100%, and don't think we ever will be or should be. Not until we are guaranteed no power failures or server outages. We still need paper backup for orders and meds at the least. MD orders print out when written, plus a summary is made every 24 hours to assist the RN in chart review.
Umm.. I think I've rambled on enough. The gist is we have computerized charts, I believe most of the users like them once they get used to them (change is always a challenge), and it solves more problems than it creates.