compuer documentation

We've been working with an Horizon computer program for ~ 2 years in our PACU. Because the bright minds in charge (and not at the bedside) didn't procure a program which interfaces with our moniters,we fought for and won the fight to keep our paper graphic records -that's where we chart our q 15 min v.s. (or more often,if needed). We thought it insane to computer chart v.s. every 15 minutes with another pt to care for as well. We are (almost) promised the $150,000 we're told it'll take to connect our computers to our moniters. Hope it comes in my lifetime.

All of our other checks - csm/drsgs etc are charted q 15 min depending on the case/complications-then I move the checks to q 30min when I deem it appropriate.

Wait a sec...you probably mean the PACU discharge assessments!? Ours are first done based on the initial set of vitals then q 30minutes in one specific area of the chart. Out of 10,the five categories are drop down boxes,horizontally placed, with scoring 0-2. Once you get to a check with a full score of 10 you don't have to fill in the '2' in each of the 5 boxes -just the '10' in the total score box - but we do chart the score q 30 minutes to indicate that we assessed the pt every half hour,as per the national standards. I don't think it'd be fully complete charting if one didn't show an assessment had been undertaken q 30 minutes...it allows room for questions to be asked about the care - I'd worry about that in a court proceding.