Charting as a Nursing Student/Graduate Nurse

[ITNurse1977]

Dear Nursing Students/Graduate Nurses:

First of all, you've chosen an amazing career and I wish you all the best of luck!! I'm a former Pedi Heme/Onc nurse who has been in Nursing Informatics for the last 12 years and I'm very interested in finding out how you, as a nursing student, learn(ed) to chart in the electronic computer systems used by the facilities where you complete(d) your clinicals. I would be so grateful if you would take a few minutes to answer my questions below:

1. Were you granted access to the electronic chart for your clinical?

2. Were you able to chart patient care in the electronic chart during your clinical? If yes, what information were you allowed to chart?

3. Did your nursing professor have strong knowledge of how to use the electronic chart?

4. If you were not granted access, how did you retrieve patient information in order to prepare for your clinical? How did you perform your documentation during your clinical?

5. Did you get training on charting prior to starting your clinical rotation?

6. Were the nurses you worked with strong in their knowledge of the electronic chart? Did they help you with it?

7. Would you like to have a stronger knowledge of the electronic chart before you graduate? The history of electronic charting? What type of questions you should ask your preceptor regarding charting? How electronic charting can enhance your nursing documentation?

8. Have you had any other experiences with electronic charting you would like to share?

[cyc0sys]

I feel like this should be a paid questionnaire. But since I was an IT guy in my previous career I'm stupid, I'll play. In school we used LippincotDocucare which is a total POS.

One of the hospital clinical sites had a nurse informatics instructors cover courses in EPIC EMR for 1/2 day. We could chart everything, pull meds, and basically had all the access as regular floor nurse user group. Our prof worked at the hospital previously and was well versed in the system.

The Veterans Administration has a mandatory online training program for CHCS. Our access was for informational purposes only. No charting was permitted. They still use an antiquated looking industrial grey GUI, operating off data tables, radio buttons, and drop down lists.

I'm confident in my electronic charting even though my facility is stuck in the 80's by way of comparison. We still use paper charts and they live and die by fax. I can't even print from the 10 yo PCs. We use Point Click Care to fulfill the basic CMS mandate for EMR. It's a total piece of garbage compared to EPIC.

[SopranoKris, MSN, RN, NP]

1. Were you granted access to the electronic chart for your clinical? Yes, for both clinical sites

2. Were you able to chart patient care in the electronic chart during your clinical? If yes, what information were you allowed to chart? We had full access to any nursing-related content in the system. The only thing we couldn't do is place or verify orders.

3. Did your nursing professor have strong knowledge of how to use the electronic chart? Yes

4. If you were not granted access, how did you retrieve patient information in order to prepare for your clinical? How did you perform your documentation during your clinical? N/A

5. Did you get training on charting prior to starting your clinical rotation? Yes, we were required to attend a class before clinicals started at each site.

6. Were the nurses you worked with strong in their knowledge of the electronic chart? Did they help you with it? Yes, to both.

7. Would you like to have a stronger knowledge of the electronic chart before you graduate? The history of electronic charting? What type of questions you should ask your preceptor regarding charting? How electronic charting can enhance your nursing documentation? (This should be broken in to separate questions). 1. I've already graduated, however, the training I received on the EMR was the same training the staff nurses received, so I felt I was well-prepared. 2. I don't really care about the history of electronic charting. Since I wasn't a nurse in the paper-based days, this is what I know. 3. Ask your preceptor if your access to the EMR is limited and how it is limited. That will let you know what you can or cannot do in comparison to the staff nurses. Also, ask your preceptor if the institution charts by exception or if you chart everything. One site I had charted everything, the other site only charted by exception. It was definitely different between the two and the site that charted by exception did NOT like it when students started charting every detail. They only wanted the exceptions from normal limits.

8. Have you had any other experiences with electronic charting you would like to share? (See above)

[onlywayoutisthrough]

1. Yes

2. No, we were not allowed to document in patient charts at the clinical site (they used Cerner). We went home and documented on docucare a lippincott resource.

3. Yes

4. We were granted access to write down information for our assignments. All documentation needed to complete assignments was written my hand.

5. In docucare during my first semester, and now we use docucae in the 4th semester. We were not trained on Cerner.

6. Yes. I was always able to sit with the nurses while they charted.

7. No. I am confident that I will be able to manage with the training I will receive at the facility where I will work.

8. No

[Purple_roses]

1) Yes.

2) Yes. I was able and required to document all nursing care in the flow sheets, as well as document within the Progress Notes. The only thing I was unable to do was acknowledge a new order or place orders myself (such as placing an order for a chaplain or adding categories for patient teaching).

3) Yes.

4) N/A

5) Yes. My group had several hours of training which included how to use the system as well as rules regarding how to maintain HIPAA while using Epic.

6) Yes. Yes.

7) No, I feel very comfortable with Epic. I do not feel the need to learn the history of electronic charting. I would ask my preceptor how I could improve my personal charting.

8) No

[NICUmiiki, DNP, NP]

Hi! I'm not a nursing student anymore, but I'll still answer. Since I went to a hospital based, BSN program, all of my clinicals were in the same facility.

1. Were you granted access to the electronic chart for your clinical?

Yes

2. Were you able to chart patient care in the electronic chart during your clinical? If yes, what information were you allowed to chart?

I could chart. We had full access and charted everything that we did.

Edited to add: We could place and acknowledge orders in the system, but were instructed not to. In my preceptorship in the CVICU, I did place orders based on protocols, but could not take verbal orders.

3. Did your nursing professor have strong knowledge of how to use the electronic chart?

Yes. My instructors would review all of our charting and would help us if we needed it.

4. If you were not granted access, how did you retrieve patient information in order to prepare for your clinical? How did you perform your documentation during your clinical?

N/A

5. Did you get training on charting prior to starting your clinical rotation?

Yes, we had to take a training course. It was the same course that new nurses took when they were hired.

6. Were the nurses you worked with strong in their knowledge of the electronic chart? Did they help you with it?

The nurses did not help us with charting. If we needed anything, we asked our instructor.

7. Would you like to have a stronger knowledge of the electronic chart before you graduate? The history of electronic charting? What type of questions you should ask your preceptor regarding charting? How electronic charting can enhance your nursing documentation?

I think by the time I graduated, I could use the program as well as any of the nurses. In the beginning there was a modest amount of hand holding, but within a few clinical shifts, we needed very little help. The only thing I wish I learned more about was the transition from paper to electronic. As someone who has never paper charted, a lot of things didn't make since until I saw how they used to chart.

8. Have you had any other experiences with electronic charting you would like to share?

Not off of the top of my head. I only answered the question based on my experiences in clinical and not as an ER tech or as an RN now.