Computer Charting

  1. Does anyone here use computer charting on their units?

    I recently started working on a beautiful, brand new unit. We happen to use computer charting, by OB TraceView. I think that the concept is wonderful, and it makes staying caught up on charting a breeze.

    BUT...we're starting to find some serious glitches in the system, that scare me!

    For example, yesterday, I saw a triage patient, and charted her admission history and assessment. An area came up on a screen which I hadn't seen before, asking for pre-preg weight and height. I thought our computer guys must've added it...filled it in. Also filled in her current assessment as being benign. Then, I saved it and logged out.

    I get out to the front desk, where our computer people are playing on the computer in preparation for an upcoming JCACHO visit...and, the areas with pre-preg weight and height are GONE, and my assessment looked like I didn't do it!!! :confused:

    Later, the lab page started showing "chlamydia" as if she had it (she doesn't), even though I hadn't put that in.

    So, the computer people and I really start messing with the system...

    We did an audit trail, and actually found the pre-preg weight and height (so they stopped accusing me of being on drugs!)...and didn't find the chlamydia on it.

    As we were doing that, we get the the medication screen, and it says my patient is on Flagyll! (In reality, she is only on PNV and Iron) My friend goes to erase the Flagyll...I hear the click of the mouse, look up, and see that she is going to erase "Iron"...So, I tell her "No, don't erase the Iron, she's on that!" Turns out, the Flagyll had literally just disappeared before our eyes, before she could even erase it!

    The admitting signature box disappeared, even though it was showing that it was enabled (should be showing up)...so, I couldn't "sign" my paperwork on the system. Then, after I locked the chart out, and we pulled it back up, the admitting signature box was there, blank...looking as if I had just forgotten to sign it!

    Several other things happened that made us think we were just in the Twilight Zone...but, I think that you get the picture...

    Now, especially with JHACHO coming in about a month and our highly litigious specialty...this scares me! JHACHO will be looking at our charts, saying that our nurses aren't signing things and such...and if someone ever gets sued some 10 years down the road, how can we really trust the paperwork???!!! :eek:

    I'm curious to see if you all are using the same system (OB Traceview)...and if you had similar experiences...how these glitches got worked out...how they're working now...

    And, if you use a different system, I'd love to hear about that one...what it is and how it is working for you guys...any glitches?

    Best wishes,
    Michelle
    •  
  2. 4 Comments

  3. by   mark_LD_RN
    use the same program never had any of those problems!
  4. by   at your cervix
    We do computer charting, but not the same system. And don't get me started. I HATE IT!!!!!!!!
  5. by   anitame
    We use a different computer system, can't remember its name off the top of my head, but I LOVE IT! I've never done paper L & D charting though, so I've probably had it easier than the old-timers, didn't have to relearn a new system.
  6. by   bagladyrn
    I've used several different computer charting programs at various contracts - one, I loved, several I didn't like and one I hated - it wasn't just user unfriendly - it was downright hostile! The one great thing about any computer charting system, I found several years ago. When named in a malpractice suit, as were all the staff working on the unit that night, I was able to be dropped from the suit without going to court because the computer system validates which terminal you are on and the exact time you are on it - so I was able to immediately show that I was not involved in the alleged incident as I was on a terminal in another patients room during the whole time - first time I ever blessed a 30 weeker for showing up in labor!

close