bedside charting?

[TZRNER]

We are a 25 bed ED each nurse usually has 4 patients the entire hospital uses computer charting, but the ED still does paper charting...ie nursing notes we write out everything we do. Well of course some nurse don't write as they go and try to play catch up before calling report or even after the patient has left. Well I for one always charted as I did or within a few minutes....Anyway now we are to start ONLY bedside charting Monday. I can see this working more so on a floor, but sometimes in the ED I am running back and forth starting lines, do EKG's, answering phone calls, giving med's and if I had to stop in that patients room write out vitals, assessments, whatever those few min's could delay my care of the next patient. Also I like to get a minute to sit and collect my thoughts and chart without the patient or family asking questions. Also the notes are to be left on clip boards in the rooms. not sure I want the family/patient always reading what I write...ie patient complains of abd pain with vomiting is eating chips, laughing, and talking on cell phone, pt states pain 10/10...SO to get to my point....is there any evidence based practice on where or how to chart when using the old fashion paper...we are 2 years from computer charting in the Ed as they are going to get a new system. This has basically came down from the CEO of the hospital do to a bad outcome of a young patient that died and a lawsuit to the hosptial. Any input would be great....I just want to give the best care to my patients!

[Larry77, RN]

I work agency sometimes and one of the facilities does what you are talking about. I don't like it at all and often do not leave the chart in my rooms because I feel like I have to be careful of what I write. Also I have noticed there is a lot less written because of this policy compared to other facilities that do not leave nurses notes in the rooms. Only thing you usually see is, to and from imaging, vitals, and meds. When looking at old charts on some of my pt's there have been some with nothing at all written...I'm thinking this is not what the power's that be would like from bedside charting.

I personally like computerized charting and PC's in all the rooms, I can type a lot faster and neater than I can write.

[peridotgirl]

What exactly is bedside charting and what does it entail?

[TZRNER]

What exactly is bedside charting and what does it entail?

You leave your nursing notes (hand written) in the patient room and chart on the patient in the room.

[vampireslayer]

We don't do paper charting, and in fact I've NEVER done paper charting! I have only worked at one hospital, and we've always had computer charting there. Having said that, I really like the option to do bedside charting, since we have PCs in every room. That way I don't have to try to remember when I did something, I chart it all right before I leave the room.

I can see that it would definitely slow you down to try to chart an entire assessment by hand, and have no real solution to that, but I would think that you'll soon get used to jotting very quick vitals, meds given, etc, which will free you up from having to that "catch up" charting.

So I have no good advice for you on any of that! BUT I was thinking about what you said about leaving the chart in the room for anyone to see. I can see that's a terrible idea, what about HIPAA? SURELY that has to be a HIPAA violation, as there will be visitors, family, etc going in and out of that room who have no right or need to see that patient's information. If you want to try to fight this issue, that's the route I'd take. You can't just leave that info. lying around for anyone to glance at.

If management doesn't agree with the HIPAA angle, if I were you I'd make sure that the papers were at least face down on the clipboard. It takes very little effort for someone to sidle on over to where the chart is lying and glance at it, but if they have to turn them over to read them, it's just a little more difficult and would take just that extra couple seconds that might discourage them from trying, for fear of getting caught "snooping". Another option I've seen is to have a hook outside the room where the clipboard is hung, with the pages turned over so the blank back sides are showing, for privacy. Then you can chart after you leave the room, and most patients wouldn't have the nerve to stand outside their room to get their chart off the hook and read it, where anyone who walked by could see what they were doing! That also has the advantage of allowing any nurse or doctor who's about to enter the room to read through the notes to get the patient's background and what's been done with them so far, before talking to them.

VS