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

healingtouchRN · Jun 4, 2003

a mixture, but mostly computer. :rolleyes: hence the carpal tunnel!

ragingmomster, BSN, MSN, RN · Jun 4, 2003

We 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!

Soulcatcher · Jun 5, 2003

We'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.

kittylover · Jun 5, 2003

We just started using the computer for all admission assessments. We still do paper charting and meds on paper, but have heard that med sheets will be the next thing to go on computer, and then nursing notes.

nightnurse49 · Jun 8, 2003

Anyone out there in LTC?

Anyone else agree with me the paperwork is horrendous? I have worked med surg, rehab and LTC. Hands down, the paperwork to keep the state and Medicare happy is backbreaking. It's all on paper. The only thing computerized are our monthly doctor orders, entering lab orders and the MAR's--which still have to be checked by hand and often need changes.

IRISHBREAD · Jun 11, 2003

we use paper for nursing but are supposed to be going to computer soon. resp therapy does computer

nursenatalie, ADN, RN · Jun 12, 2003

We are currently using both systems; paper and computer. Some things are "double documented" during this phase of switching to paperless. Im sure it will be better once we get completely switched over but for now it is a real headache!

Marie_LPN, RN, LPN, RN · Jun 16, 2003

we use computer

Editorial Team / Admin · Jun 16, 2003

Computers: CPRS and BCMA.

I'm curious WHICH computer systems are being used, and what kind of feedback ppl have about using them.

Used Medi-tech at previous facility - VERY cumbersome!! (and we weren't even fully using it yet!!)

So far like CPRS system. Comments????

Marie_LPN, RN, LPN, RN · Jun 16, 2003

Siemens is the program we use, only bad thing about it, it makes random dinging sounds without even touching the computer

TreceRN · Jun 18, 2003

Our facility is currently living in the "limbo" world of part paper, part computer:confused: We implemented order entry many years ago (docs write the order on paper and then we input the orders into our computer system, which is interfaced with our lab system, no paper). We also input height/weight and general admission history. Physician H&P and consults are put in the system via our dictation system. All labs, ancillary notes, dietary etc in in our system. We "go-live" with the rest of nursing documentation, including care plans and "work lists" in November. Our system is called "Lastword" and we are able to actually customize a lot of what we do based on end user feedback. I think it's great, but many nurses are naturally freaking out about it :eek: Fear of the unknown, accompanied by an adversion to change can make for some seriously vocal opponents, but as Tim Porter O'Grady MSN says, "either get on the bus and go for the ride or get off now, and I'll even help pack your bags". Technology is here to stay, I just hope that those decision makers regarding systems and functionality included NURSES who will have to use it!

mystc42 · Jun 23, 2003

When I came to the hospital last year they just had the paper system, but we switched to computers about 6 months ago. I didn't like the switch over at first,but once we got use to the idea it all became much better. We use computers for everything. We have charts where we print our days worth of charting on there and keep up just incase the system were to go down. But we actually use a barcode system where we scan the pt id bracelet then scan the meds. It prevents medication errors but is still a pain sometimes. But if it saves one life then it is worth it. Our system also corresponds with the surrounding doctors offices so it saves us time there!