Computer charting...love it or hate it?

knob · Mar 19, 2008

As a student in a rural area that has some larger cities (and hospitals) fairly close by, I've gotten a chance to use both during my clinical rotations.

Being a computer nerd, perhaps I'm a bit biased, but I greatly prefer computer charting. I can type much faster, it's a lot more legible (My handwriting is atrocious), and as a student who doesn't always remember to include everything, the ability to just go up and type in what you forgot to include is incredible (As in, I'm charting a head to toe, in that order, and I forget to include the apical, lung sounds, or bowel sounds. Instead of having to write those at the end, I can just scroll up to where it should be and include it. It's less messy.) Best of all, there's BACKSPACE! If I accidentally misspell a word, I can erase it and retype it, instead of putting a line through it.

Not to mention, if the computer has internet access and you're completely unsure how to spell a word, Google is only a click away (I make frequent use of that).

Also, going back to forgetting something while charting, at least one hospital I've been to has had canned text with their charting. You just fill in the blanks and add what you need as you go. It makes it clean and easy. Granted, it'd be easy to get lazy and just plow through it without adding anything relevant to the patient, other than what is presented to you on the screen, but if I ever get that way, then I'm not doing my job.

JaredCNA, CNA · Mar 19, 2008

What program does your hospital use....we use Cerner. It's OK, but we still have paper charts that the doctors write their orders in. The charge nurse then puts the new orders into Cerner.
We still have paper interdiciplinary plans of care, moorse falls sheets, education pathways, and a bunch of other paperwork that could easily be put into the Cerner system. It seems like a lot of double charting occurs IMO.

We use Wizard. It's also called Epic (Hyperspace) in some places. The travel nurses we had were familiar with the program, so I guess it's widely used.

All of the things the OP mentioned are all in the system and not on paper, except the doctor's still write orders and progress notes by hand. Lab results are in the system, but also in the paper chart. Tele strips are in the chart also, although they are thinking about putting them on there.

barefootlady, ADN, RN · Mar 19, 2008

Meditech user x years. Not nurse friendly, no matter how hard you try to push for better way to chart, TPTB won't listen. Oh, for the days of flow sheets and charting by exception. I would even do SOAP again. LOL!

pagandeva2000, LPN · Mar 19, 2008

We use MediSys. I prefer computer charting, because it is easier to pick up orders, documentation is a lot easier and once started, the history of the patient is there for us to see. Labs, health maintenance (vaccines and PPDs) are there, a section for allergies, medication administration, doctors and nursing notes are all included. Also an area for patient problems for a history. What the issue can be is that, as usual, there is no guarentee that the information is correct, but, at least I can gather as much as I can to make a clinical decision.

TRAMA1RN · Mar 19, 2008

I have used EPIC and loved it! Currently am using paper charting and hate it.

BrokenRNheart · Mar 19, 2008

Cerner and a couple others.

Computer charting takes longer than paper and takes away from bedside care. Period.

Even patients are noticing that we are always sitting at computers trying to get work done.

I have nothing against computers or working on them. I love computer work. But it takes longer and threw more imbalances in the day!

zamboni · Mar 19, 2008

Meditech user x years. Not nurse friendly, no matter how hard you try to push for better way to chart, TPTB won't listen. Oh, for the days of flow sheets and charting by exception. I would even do SOAP again. LOL!

+1

Meditech is old and outdated considering what else is available out there. Bulky, cumbersome, and good luck trying to find info in a hurry. We've actually had to quit using computer charting in the ER, because it took too long to just find a C/C. The floors still use it though, and it's a royal pain for them to have to go in and start all the info, after we've had the patient for 12-14 hours and haven't put anything in the computer. I feel for them, but I'm not triple charting.

AuntieRN · Mar 19, 2008

We use Meditech too...youre right it stinks...our ER doesnt use it for anything really either so we have to go and put everything in it. It takes forever to enter orders and check them...takes forever to find anything....but it still beats having to write everything down. We use paper charting for all doctors orders, progress notes and our graphic sheets where we chart vs and i&os and any kind of home health info for discharge is placed in the chart. Its really not too user friendly

FlashGrad · Mar 19, 2008

We use Epic (hyperspace), and I think it is very easy to use. The downside is that we still do some paper charting. The assessments, treatments, etc are still paper. I have heard eventually everything will be computerized.

RNperdiem, RN · Mar 19, 2008

The doctors here to computerized order entry, and the nurses have recently been swithched to computer charting.

I prefer the paper. The flowsheets we used were well-designed and easy to use. I could document vitals and assessments in the time it takes to log on, select patient and start clicking.

There is a trend I don't like either, the doctors have remote access to the computer nursing flowsheet. They sometimes write orders depending on what the screen shows. The doc never has to visibly go look at the patient; this creates the risk to treating the numbers and not the patient.

ak127 · Mar 19, 2008

I am a pro-computer person in general, but some of those systems were really not written with nurses in mind. Also, if its half on computer, and half paper, you're really just spending twice as much time! AND if I'm doing this stuff on a computer, MAKE THE MD WRITE ORDERS ON THE COMPUTER! Also, three of the hospitals I have been at use these huge wheeled carts with computers on them. If you're going to do it, give all the nurses and techs hand helds so that charting can be done right in the patient's room without rolling a COW around (yes, we called them COWs, computers on wheels, and they weighed that much too!).