Standardized computer charting--opinions?

The Little Greek · Feb 07, 2008 08:45 AM

Hello everyone,

I recently started a new job where the computer charting system offers "standardized" responses that you can click on to add to your notes. For example, the drop down menu will have things like:
"ID band in place"
"Allergy band in place"
"Bed in low locked position"
"Call bell within reach"
You get the idea. There are also options to choose regarding IV site checks, assessment, medication administration, etc.

The is the first time I've encountered such a charting system and I do not feel comfortable with it at all. I like to chart using my own words, however the higher-ups encourage the use of these "canned" phrases because they conform to Joint Commission standards. I continue to chart in my own words regardless of what they say. Turns out that it served me well in a recent situation where one of my antepartum pts delivered in the bathroom at 25 wks with a bad outcome.

Does anyone else have experience with "standardized" charting? What are your opinions? Thanks in advance!

Dixielee · Feb 07, 2008, 09:12 AM

I agree, I hate the computer charting. I like having labs, x-ray reports and previous visit records quickly available, but just using the canned responses can make every chart look alike. I am in a very busy trauma center and we don't use the computer for trauma's, MI's going to the cath lab and Codes, but we do for many other unstable patients.

It is quite tedius charting drip titrations and vital signs every few minutes on a computer...much faster to do by hand.

I use the canned responses for routine, stable patients and uneventful visits, but if anything out of the ordinary or anything that makes me feel uneasy, I am hitting the "other" button and charting a narrative.

As nurses, we have always had to adapt, even with adapting appears to make no one's life any better. I think this is one of those cases.