computer charting

Nurses General Nursing


Specializes in ortho,icu.

Hi everyone. I really would like your opinion about charting. I am trying to find new and better ways to increase our patient care and less time behind the key board typing. I see doctors dictate their H&P all the time, can you imagine if they had to spend time writting out the H&P. No one would be able to read it and they would not have the time to sit and type it out. The other day I stayed 2 hours after my shift ended to chart. I thought to myself their has to be a way we can chart on the computer without having to sit and push the keyboard. Do you think it would save us time if we could dictate as we go, everything would be accurate and we would have more time with our patients. Thanks, Wilma

Specializes in Case mgmt., rehab, (CRRN), LTC & psych.

I think that dictation would be a time-saver for nurses.

I'm feeling very fatigued at the present time because I worked a 12 hour shift last night and had to stay over one hour to finish my paper charting on 10 patients while doing other stuff (counting the Pyxis, lengthy report, etc.).

I've seen charting by dictation done at a facility I had clinicals at...however, I thought their method was unprofessional, as it required the nurses and CNAs to wear headsets and dictate their charting AS they performed procedures--even when walking through the hallway. I thought it was very risky and saw a lot of cases where HIPAA was or could easily be broken. However, I only saw this from a distance as a student, so maybe it works better in actual practice if you're careful.

The cynic in me says that if the hospitals give nurses dictation they will give the nurses more patients to care for since now they have more time.

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