Bedside Charting

je_da · Mar 6, 2008

in our facilty, we do have computerized charting. It is a cart with the computer attached to it. for me it is very convenient because you have an easy access to your assessment, meds profile, lab and etc. although the doctor's order is always attached in the chart, you could always go to the nurses station to check new orders.

when you do assessment at bedside you could easily put them in the assessment portion or make a note and put them in later whenever you have the time and just adjust the time to when you actually did assess the patient. when you give meds, you take your cart in the patient's room and prepare your meds or prepare them before you get in or whatever is easier for you, then inform the patient what meds youre giving and then scan there armbands or ask their full name and DOB.

you are actually outside the patients rooms in the hallway with your computer cart. when your patients need help, or the call light is on. then you can just easily go to them in seconds and address their needs.

if you have a pocket phone, it has its advantage and disadvantage to it. when you need to get hold of an MD for patient change of condition or critical values, you can call them right away. but when you are in the patient's room and doing some procedures and your phone rings, then you are interrupted. its up to you to answer it or not. but answering it and telling them your in a patient's room and ask for their number for you to call them back - is much better than not answering them at all.

i hope i answered some of your questions.

amy0123, BSN, RN · Mar 6, 2008

We have computerized charting. It's really different from paper charting for more reasons than I could come up with now.

The computers are on the wall in the hall or in the nurse's station. Includes the MAR, new orders, current orders, labs, pt's admission, assessments, history, allergies. Any doc or NP could walk up to one in any part of the hospital to enter an order or anything else. It's a time saver.

The MAR is simplified. Very easy to see what time to give a med. The meds due are highlighted for you. If you don't know about the med, you could look it up right there on the provided program. Then all you have to do is click that you gave it and you're done.

Progress notes are typed in. Discharge is done with a few clicks then printing out a form for them to sign.

In my experience with paper charting, the biggest prob was reading the handwriting and abbreviations from doc's and nurses and anyone from the healthcare team. We don't use abbreviations in my hospital. That makes communication a lot easier without any misunderstandings.

Sometimes the papers fall apart in the chart. Sometimes the binder is falling apart.

I love computer charting! Very organized. We use the eclipsys and sunrise computer charting.

Ruffles 1 · Mar 10, 2008

I would love for our hosptial to have palm-pilots or use computers at the bedside. All the other nurses laugh at me when I try to explain that this would be so much more efficient and save us time with all the paperwork. They have been talking about this ever since I have been working at this hosptial 7 years now, going "paperless". Thanks

amy0123, BSN, RN · Mar 10, 2008

I would love for our hosptial to have palm-pilots or use computers at the bedside.

I would love computers at the bedside!! As a nursing student, I've seen this. You could assess the pt then immediately document it right there at their bedside computer on the wall. Doc's could put in orders right there too.

Ruffles 1 · Mar 10, 2008

I hope the docs will put orders in the computers, but I am a little worried that we as nurses will have to put in verbal orders? I hope that would stop but I have a feeling we will still have to do that?

amy0123, BSN, RN · Mar 10, 2008

I hope the docs will put orders in the computers, but I am a little worried that we as nurses will have to put in verbal orders?

Since we've had computer charting, I haven't taken any verbal orders.