computer charting is killing my career

Suninmyheart · Jun 12, 2013

In hospice I tried to create a flow to the actual visit and assessment to match how the assessment charting was set up. But of course that would not always work because visits with patients are unique and certainly not cookie-cutter. Most importantly, I would never put the computer between me and my patient. I created an environment where I could be present to the patient and somehow include them in on the charting process. I would say out loud parts of what I am typing and if done well can become a valuable way of paraphrasing and charting at the same time. It really works! I have had patients who tell me they appreciate my thoroughness and they feel listened to when they know I am documenting all their concerns and needs. Ha! But of course there are those visits where nothing goes smoothly and charting even one word is impossible.

Sterlink · Jun 12, 2013

I am trying to chart later...stubbornly trying to jot paper notes and catch up with the laptop later. I'm thinking I have got to stop this and work that machine into the visit.

AnneP726 · Jun 12, 2013

...and work that machine into the visit.

That's what saved me.

wooh, BSN, RN · Jun 13, 2013

I am trying to chart later...stubbornly trying to jot paper notes and catch up with the laptop later. I'm thinking I have got to stop this and work that machine into the visit.

Yep, you're just doubling your work.

Most important thing is to work WITH the program instead of trying to make it work with you. Don't think, "I need to chart this, how do I make it fit?" Instead think, "It wants me to chart this, this, this..." THEN, if after you do that, there's something left over to chart, add a note.

And if you haven't, learn to type. Mavis Beacon really does work. You can do more looking at the patient while you're putting your information in because you won't be looking at the keyboard. AND you'll get narrative stuff in lots faster.

St_Claire, ADN, RN · Jun 17, 2013

I keep the laptop on my lap and go through the OASIS then the care plan. I put the laptop in my bag and do my assessment making notes in my notebook, I also note what I taught, issues, etc. then when I get to my car I do the nursing note and put in the vitals. Make the laptop your friend.

Sterlink · Jun 18, 2013

I keep the laptop on my lap and go through the OASIS then the care plan. I put the laptop in my bag and do my assessment making notes in my notebook I also note what I taught, issues, etc. then when I get to my car I do the nursing note and put in the vitals. Make the laptop your friend.[/quote']
That sounds interesting. I might try that. Now a stupid question.... What do you mean by "the care plan?" Are you referring to a start, or a revisit?

Isabelle49 · Jun 18, 2013

Do you have space in your program to jot notes. We have a narrative section and occ I jump to that and enter in shorthand anything that I will want to include with my final narrative or anything I will have to put in the right place later. We are using Androids.

Benedina · Jun 19, 2013

I create a Word document on my laptop for each patient. In the home, I open the software chart and use it to fill in vital signs and physical exam directly. Anything extra, I write notes into the Word document ("call MD @ WOC orders, dtr worried about approp snacks")--that sort of thing. This is a good compromise for me: I can do the care plan & visit note later from my notes, but I have hard data already entered into the computer.