Computer documentation

ICUNurseCline · Mar 10, 2009

I use powerchart. It took a while to get used to it, but now that I have, I love it. I think it provides better continuity of care across all disciplines. I agree with a previous response: CHANGE IS GOOD. Not only that, but the ONLY constant in health care is change. Accept it, encourage others to, and try to look at the positives!

stressgal, RN · Mar 15, 2009

I too agree change is good and computerized charting is here. We use meditech, not all processes are the best and it doesn't always flow the best but it's what we have. "New/younger" nurses have few problems with the computer charting issue, "seasoned/older" nurses at times struggle and face challenges with it. I have found it easier to work with IS and our informatics director than to fight against it. Best to be a champion for change.

Pediatric Critical Care Columnist · Mar 16, 2009

We just went live on March 11/09 and only on two beds. Our system is a custom Picis that is already outdated when we look at what we're actually doing now. We will still be doing about 70% of our charting on paper... only our VS, fluids (manually entered) and routine care (also manually entered) will be recorded on the COW. The system will only be in use in the ICUs and it doesn't interface with the program in use in the OR. I'm not really sure why we're going piecemeal like this but it's like eveything else our hospital does. I've been on vacation since the 6th so I have no idea how things are going.

Ruby Vee, BSN · Mar 16, 2009

i've been using computerized charting for over a decade, and although i initially resisted the change, i've found that i love it now. it really does save work! it calculates our drips for us, will calculate cardiac index, svr, pvr, lvswi, etc. with just a click of the mouse. most of the assessment can be done via mouse clicks (as opposed to free texting) which many of my colleagues appreciate . . . not everyone learned to type. notes are legible. my biggest complaint is that we have too many computer programs to use which don't talk to each other. outpatient clinic notes, labs, x-rays, etc. are on one, inpatient nursing documentation on another, order entry and e-mar on a third, inpatient radiology results on a fourth and then you must text-page your providers using a fifth, look up unfamiliar drugs on a sixth, and pharmacy has two more programs that they use which also don't talk to our programs. one integrated program that does everything would be wonderful!

I_LOVE_TRAUMA, RN · Mar 16, 2009

I love our computerized charting! We have zero paper charting now. Even the MDs and APNs all enter their orders online, we chart everything online, even things like ordersets, conditional orders, etc. Everything is cohesive, and talks to each other, and each time we log onto our pt's chart it tells us if we have new orders, new results, etc. We are a teaching hospital, and recently we have had a lot of people checking on our system, MDs from the military and from places like Yale, they all love our system and say it is much "smarter" than anything that they have ever used. I have been a nurse for awhile and will never go back to a place that uses paper charting/outdated systems, what we use (esp. the barcoding) is so much safer/legal.

Bella RN, BSN, MSN · Mar 26, 2009

I loooooooooove computer charting. So fast and efficient. Sometimes you want to find out what happened the previous shift but don't know the writing based on paper--much easier to look it up on computer.

I am at a facility now that does paper charting and at first My nose was in the air, but i got used to it. I like being able to chart meds and do my assessments on computer.

I read that by 2012 all U.S. hospitals will go to computer format. I heard that the VA has the doctors enter their orders by computer themselves...I wonder how that works???

I_LOVE_TRAUMA, RN · Mar 26, 2009

At mt facility the physician's enter all of their own orders themselves-they are required to whether they are at home or not. We are only allowed to enter orders for them during dire emergency situations. It has saved us sooo much time, and has decreased errors a lot.

Pediatric Critical Care Columnist · Mar 26, 2009

Our electronic charting package was rolled out two weeks ago while I was on vacation. I had my first experience with it yesterday. I think once I get used to it and know where different things are, what they're called and how to capture what I need to capture it will be tolerable. But I don't think it will be the panacea that others think it will be, because we're still going to be documenting the majority of our information on paper and the only areas of the hospital using it will be the ICUs. We've also had numerous complaints from families that we're spending more time nursing the computers than we are the patients. Another huge issue for us is that the plan was cobbled together and launched without looking at logistics or ergonomics. We have electrical cables running all over the place... I rolled my right ankle three times on the one at my bedside yesterday. We have COWs that block the view of the patient and take up a huge amount of space at the bedside. I must have walked two extra miles yesterday getting around the equipment at my own bedside while trying to help the docs put in lines and obtain diagnostics, gathering supplies from other areas of the unit that I couldn't get to without going all the way around and so on. We were short on space before; now it's actually dangerous.

meandragonbrett · Apr 2, 2009

We use meditech and and it's an absolute nightmare for me. I'm one of the younger folks and I hate computer charting. Give me a paper flowsheet and let me write it out! Our other issue is that 1/2 of our computers never seem to be working properly or they are extremely slow and it can take a good deal of time trying to get them to work properly just so that you can sit down and chart.

I would love to have a system that imported our vitals from our monitors. That would save us so much time!