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Computer charting- How often do you document vital signs

cfbrown cfbrown (New) New

We recently starting computer charting in our small community hospital. What they did not purchase was the interface from our monitors to pull over the vital signs. It is very time consuming to enter them all in the computer manually. Most of our pts are on pressors and our policy is that any titration must have vitals documented when it is done. How are other hospitals in this same situation handling this issue? The rest of the computer charting has gone very smoothly, it is this one issue taking up a lot of our staffs time in ICU. We will try again in next years budget to get the interface approved, but I am not hopeful that it will happen.

I don't know about your charting system, but the one I use in ICU is directly connected to the monitoring systems. This means that vitals are continuously monitored. However, we are required to do an hourly vitals check, where we also enter urine output, temperature (if no PA cath), pain level, RASS score, etc. If we are investigating when a certain event, say sinus tach, occurred, we can set the time interval to every 5 seconds to see exactly when it began and how high the rate went, etc.

For certain procedures, blood transfusion, for instance, we do more frequent vitals checks also.

Our charting standards are no different than when it was paper documentation. We do not have the interface either. All of our vitals and titrations must be keyed in by hand. It can become very time consuming when you've got one patient on levophed and the other on epi (Our policy is q15m vitals for the entire duration of the gtt.)

BacktoBasics

Specializes in ICU/CCU, PICU.

Our system doesnt pull any information. I was wondering if they were systems out there that do and I guess they are!

By default our vitals are at minimal q 2. You can always add more of less. I usually add another and after prior to any vaso,sedation, drip changes and bp meds. Occasionally if were like titrating their peep high ill documented pre and post change.

littleneoRN

Specializes in NICU.

Our charting standards are no different than when it was paper documentation. We do not have the interface either. All of our vitals and titrations must be keyed in by hand. It can become very time consuming when you've got one patient on levophed and the other on epi (Our policy is q15m vitals for the entire duration of the gtt.)

Oh my! If I had q 15 min VS to chart on two patients without monitor interface, that would pretty much be 1/2 or more of my day!

General E. Speaking, RN, RN

Specializes in floor to ICU.

This is what we have to do also (hand document Q15 min vitals when on pressors). We are going "computerized" soon and I have heard that this will no longer be necessary as they will be recorded through the computer system. Hallelujah! What a nightmare sitting at the monitor trying to "catch up" 7 hours of 2 patients on Q 15 minute vitals. What a waste of time :uhoh3:

TulsaTime

Specializes in Critical Care, ER.

when i worked in a system with computer charting & no interface we still did our frequent vitals on paper charting because of the huge amount of time it took to put it all in the computer. we entered hourly into the computer but all our 15 minute vitals were on paper

Thanks for the replies.

Hopefully we will get the interface next fiscal year and this will become a non issue. We discussed documenting Q 1 hr on the computer and otherwise on paper, but the MD's wanted everything on computer so they can log in from their office to view the trends.

For anyone out there who has not gone to a computerized system yet, make sure the interface from your monitoring system to the computer is included when you purchase your system. Otherwise your nurses will have to spend a lot of time documenting vitals.

Biffbradford

Specializes in ICU.

I've documented vitals minute by minute if I was madly titrating drips. Drives 'ya mad, but then I had all my moves covered by the data. :uhoh3: We had laptops in the room with us as well as one outside in the hall, so that did help.

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