Quote from thisismylicense.rn
Any PACU nurses out there already doing EMR charting? Last week our hospital went "paperless" for preop and PACU areas. This involves using several file sheets for documenting assessments and vital signs. In preop, I have not found it to be a problem - you have the luxury of focusing on the patient without any crisis at hand. You record in the computer as you prep them without any interruptions.
PACU is a whole different scenario - you may spend the first fifteen minutes securing airway/suctioning/running to pyxis for pain meds/applying warm blankets/orienting pt, reassuring them/etc. etc. The PACU assessment forms in Meditech are not user friendly. You have to add the PACU interventions and then delete the duplicates if the patient went through preop, and that is before you even begin charting..... You have to manually enter the vitals every 15 min, just a whole lot of clicking. . . . . .
I feel frustrated that I have to fumble with the "WOW" - workstation on wheels- more than with my patient now......
I know that IT says that once we get more familiar with the system, things will go smoother; but I seriously have my doubts. Any advice???
This time last summer I was EXACTLY where you are now, thisismylicence.rn. Because the powers-that-be decided that the entire Perioperative portfolio had to be 100% computer-charting,PACU was stuck with a really awful (in our opinion) program that we had to use,as it came with a package deal that was purchased some time ago. The PACU nurses,once we had a look at this thing -protested MIGHTILY - it was essentially met with 100% negative reviews by the nurses-except by some of the 'super users' who were first taught all the ins and outs of the program,so that they could teach us. I mean it was met with A LOT of flack (and for good reason) -luckily, on our suggestion,many modifications were put into place that made it better -don't hesitate to do this,too.
One of our biggest beefs was (and still is) that our moniters didn't/don't interface with the computers (even 2 new generations we've had since don't!!)....so initially they were expecting ALL vital signs would be entered by hand....yeah,riiiight,in a unit which minimally records them Q 15 mins and Q 3 mins if medication has had to be given to treat hyper/ hypotension,or if someone is crashing
We fought tooth-and-nail to keep our paper v.s. record. So far,so good. Our ultimate wish is that they find the $150,000 they tell us it'll require to link them up.You don't have that problem...good.
We were supremely worried that pt care would be compromised due to needing to fiddle around with computers, and balked at the thought that we would EVER get comfortable (and efficient) enough to favour them. Well,with some good,solid planning by nurses,many of us love the computers now (last week I came on duty after vacation to find out that the Horizon program was down -some glitch,and I was actually disappointed! If you had told me that a year ago...:typing
What we nurses have put into place are:
Scratch pads at every spot on which we write down the admission v.s.,the drsgs,the csm checks,the drains and tubes,the iv details,the particulars from the anesthetists' reports,etc - if we're lucky - another RN or more,is doing all the settling work -zeroing art lines,getting the warmies,putting ivs on pumps,etc while we start the chart. If we have to do the entire admit ourself,then quite often someone else will do the next check due on our other case.
Unless it were an extreme case,we DON'T take a 2nd case until the first case's admission has been logged in -they were going to have us not be able to refuse a new admission while this was done -but we changed their minds
The anesthetists don't like to be put on hold,but that's the name of the game, at times, now. I must say,these nurses I work with are excellent,and you never see games being played in PACU -if a room (s) is on hold -it's on hold for a darn good reason. And puffed-up surgeons storming in don't scare us...we're all adults here, people...
A great benefit to having this system in place for the pt's entire perioperative course is that,if I have time before the pt rolls in (and I usually do) I can find out all kinds of info that I'll need -the preop v.s (with which we use as part of figuring out if the pt meets discharge criteria -like yourselves,no doubt), their PMHx,the meds they're on, what the surgical procedure was,the type of anesthetic used,whether they had local as well as the G/A or spinal, the meds given preop,etc -it's invaluable in that way.
Hang on, good luck,and don't hesitate to make suggestions to make it a better system for you