Tell us about your computer system - page 4

If you have Computer Charting at your job, please start a new topic in this category. Tell us if you like it, or hate it. Enjoy! ------------------ Brian Short WORLDWIDE NURSE: The... Read More

  1. by   KellRN
    I work at the same hospital that I did my clinicals in for school, and we have had computer charting since I have been there. I love it. There are definitely more pros than cons. I know this because we have had to do paper charting a couple of times due to technological problems. The differences I found was that with the paper charting, there doesn't seem to be enough room to document some things. Another problem I find with it, is that some nurses' handwriting is difficult to read. I love the computer charting because each body system has a page of its own to document on. I don't have to type a lot because there are places to probe specific things. Another reason I like the computer charting is because it helps to be sure all medications have been charted. I just have to go to the medications page for each pt and probe the time I gave the medications. At the end of the shift, I do an end of shift check, and it shows any medications that have not been charted. There are many other reasons the computer charting is better than paper charting, but I don't want to go on and on.
  2. by   l/drn
    Originally posted by bshort:
    If you have Computer Charting at your job, please start a new topic in this category. Tell us if you like it, or hate it.

    Enjoy!

  3. by   l/drn
    i am an rn in a small community hospital (apprx60 deliveries/month). we started using the watchchild fetal monitoring and charting sysytem about 2 years ago. it's nice in the way that i am able tochart as events are happening, but it is still necessary to do a ton of pen/paper charting (ie, meds, labor flow chart, admission record Etc). most of the charting done on the computer must also be documented in pen elsewhere, at least that's our hospital policy. so essentially we're double and sometimes triple charting, so to me, what's the use of the computers????
  4. by   juliekrn
    We are in the process of going to Invision charting for our pediatric and womens health patients. Any help in writing screens would be appreciated.
  5. by   rninformatics
    Feel free to contact me if I can be a resource. Will the application be used in a clinic or an acute care setting?
    http://informatics.nurses.nu
  6. by   bbnurse
    First, the LPN scope of practice is to reassess. Once the initial assessment is done by the RN, any shift assessment is a reassessment and, as such, is acceptable for LPN to do and to enter into the meditech system. Just have the delineation made in the policy that it is a reassessment. It is now unacceptable practice for RN to co sign for such things..We are just starting our Meditech computerized charting and find it some duplicity right now but it will get better with all the new updates being provided and the interfaces between monitors now available. It will save time and prompt more focused plans for care and benefit the pt., satisfy regulations and physicians and educate some in advanced critical thinking.
    Originally posted by MED/SURG NURSE:
    We also have had Meditech for 2 1/2 yrs. Many good features, and we are still learning ways to customize our programs. One area we are trying to figure out now, is how can LPN's document assessments and notes within their scope of practice? Before with paper charting, the RN's would co-sign LPN's documentation, but that is not possible with our Meditech system. If anyone out there uses LPN's in the acute
    hospital setting, how or do you have them document on Meditech within the "Rules"?
  7. by   psych-rn
    I am a Clinical Nurse working in Nursing Informatics. The hospital is a psych hospital only. The system used currently is Excelcare and soon will become E-Care. I am desperately attempting to round up information on these systems re: psych and any problems or successes found. I am also wanting to know if there are any psych hospitals using other electronic systems anywhere in the world? This information will be very handy as I'm wanting to apply for a scholarship that allows me to travel to another hospital(s) and compare information thjat may assist in improving health care here in Australia. Can anyone help? My email is in my personal details.
  8. by   Boosan
    I work in a 110 bed hospital. We do have computers, but as for electronic charting it's a joke. We can pull up all the other departments to order labs, x-rays, and meals. But we still have to hand write all the patient notes, medications, assesments, etc. Orders are still handwritten and transcribed by the wardclerk/nurse. We still give oral full reports to the oncoming shift. The main office keeps telling us SOMEDAY we will upgrade. But after seeing all of the layoffs, and cutbacks I really don't think we will ever see any type of upgrade to our hospital. I feel like we will be lucky if Houston doesn't try to close us down in order to keep Beaumont open.
    Any coments?
  9. by   freddy
    Originally posted by SLee:
    Does anyone work at an institution that has computerized nursing documentation that is intuitive? ex: When you do the assessment, the system will formulate a preliminary care plan for you and then allow you to add, edit, or delete as necessary? Also, as further assessments are done, it will update the care plan based on the most recent assessment.?
    My LTCF/Rehab (121 beds) uses a system like you describe, only the care plan is not automatically updated. However, a new preliminary care plan is generated from each MDS. The system is Management Data, Inc., or MDI. I also replied to a posting under "Long term care plans" regarding the system. I am Care Plan Coordinator at my facility and really like the system so far. We have been using it since July 1999.

  10. by   laurasc
    I work in a pediatrician's office and we run a medical records program called "MacMedical."

    There's the actual patient charts, which is called MacMedical Records, or MMR. We do all of our charting on the computer. Test results and typed letters can be scanned into the system. Hand-written consults and letters have to be stored in the paper charts. It's working alright now, but it was rough at first. The most tedious was transferring records such as vaccination dates and PMH to the computer...something that I had to do most of.

    The system also includes a complete billing and scheduling system.

    We have a computer in the examining room, in my office, the doctor's office and two in the reception area. The nice thing is that I don't have to run to the reception anymore when I want to schedule a patient for another day.

    Laura
  11. by   toronto rn
    The hospital I work at started using computer charting last year. The actual flow sheets used on the program were developed by the nurses, and are still undergoing revision, but the initial aches and pains are pretty much overwith. All the monitors ventilators and iv pumps are integrated into the system which allows you to just click and download all your VS and Vent signs. The integrated system will store minute by minute information for 72 hours allowing you to chart late entries with real time information. Downfalls I've noticed is that it is not as easy to retrieve info. (as a flow sheet would be) I have not yet learned to like charting by exception. It is timesaving to have labs and orders accessible at the click of a mouse. Big downfall is I find it more difficult to remember information about the pt ie last bp vent signs etc. The loss of physically writing things down seems to make it more difficult to recall, as a result I still tend to keep a mini flow sheet in my pocket for jotting down this kind of info, so much for paperless!

  12. by   Y2KRN
    Miss the electronic charting. I am a new nurse and my first job I took just implemented computerized charting. It was a great time to start because the staff was learning the system as well. We used the CPSI system, now I work at a facility that still hand charts. Our computers had touch screens and you could chart by exception. The only draw back was the MAR's however at the time they were troubleshooting the difficulties and I am sure by now they have been worked on and improved. I miss the admission part the most there was not 50 different papers to fill out for the admission process.
  13. by   PedsRN3
    I'm a float in a children's hospital and there are 3 types of computerized charting that are used in the hospital--Meditech on the inpatient floors and OR, the Marquette QMI(?) system in the ICN and another used in the ER (I don't float there so I don't know the name). The PICU continues to use paper charting while deciding which computerized charting to go to.

    I have used both MEditech and the ICN systems extensively and I like each for different reasons. The ICN system is nice because the vitals automatically "drop" into the charting at specified intervals. You also don't do any lengthy patient notes, everything is down with a "pull-down" menu. It is also a plus to have all the social work and discharge planning on this system too....makes for much easier discharges. The one thing I don't like is that we still have to use MEditech to do "order entry". Meditech is nice because everything is right there...your assessments, social work notes, lab values, etc.

    We still have paper charting for everything the MD does....we were told this will eventually change. With our med orders we also use a paperless system....our orders are scanned down with the Pyxis system and the pharmacy completes the orders.

    I do not like that the PICU is still using paper charting because after the pt is transferred to the floor we have no real way of looking up assessment trends without going through the paper charting....we don't have that information "at a glance".

    Overall I really like computer charting....don't ever want to go back to paper charting!!!

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