Computer Documentation, is it really better?

Editorial Team / Admin · Nov 2, 2005

Our hospital just went to computer documentation, citing the fact that it doesn't allow for "creative charting," rather standardizes it for everyone. The nurses on my unit feel that upon reviewing charts, it is more difficult to follow the flow of care. We work in labor & delivery, one of the highest areas for litigation, so we are all concerned. Everyone has heard of cases where the computer malfunctioned, a case went to court, and the documentation was unable to be retrieved. Is this a legitimate worry and are we at risk?

In a nut shell, yes, there is room for concern regarding the computer documentation especially in OB. You are not able to make any narratives on paper/flow charts???

llg, PhD, RN · Nov 2, 2005

Your question was one of the central issues that led to my doctoral dissertation several years ago. I was (and still am) concerned that most people just assume that computerized anything is always better without considering both the postive and the negatives. By pursuing a more balanced view of computerization, I found myself quite unwelcome in the nursing informatics field and not able to pursue a career in that general direction.

I am happy to hear that others are starting to ask some of the same questions I was asking a decade ago. Perhaps the industry will soom be ready to address them.

llg

KatieBell · Nov 2, 2005

I have found that using the computer for documentation has made my documentation better for certain things. I think it also depends on the computer software. I've used 3 different systems now. Some were actually more cumbersome than writing it down. However, for me in the ED, I actually like using Wellsoft. When we went to it, there were a lot of complaints, now when it goes down, there are a lot of complaints. We still print out a paper copy of the chart. When the computer system decides to go down, there is usually some sort of warning though it did one time go down in a storm, everything was saved on a specific dedicated server, and none of the charting up to the crash was lost.

I personally like computer charting because I am a fast typist and it takes me less time to chart typing than writing. In addition, someitmes the templates remind me of a small area of assessment that I saw and assessed and wouldn't normally remember to document! There are some odd things about the program, when they first started it, some of the software engineers came and worked with us for about a month. They customized some things for our specific unit and added some drop down notes for things we use all the time. So, maybe if you have an opportunity to work with the software guys you can stream line it more for your area.

I'm traveling now to a place with paper charting, and I feel the charting really is not as thorough but it could also just be that this is the culture of the unit (to not chart a lot....)

storkbynight · Nov 4, 2005

We are currently using watchchild in conjunction with the computer charting (they don't interface), so we can put narratives in there, but they say eventually they want us to stop using wathchild & use it solely for monitoring. We can always write long nurses notes, but in general, I worry about computer down times (day light savings for example).

SFCardiacRN · Nov 5, 2005

Computer charting has made my life so much easier. It took a year to really get used to it but now I love it! I can access any patient from any computer in the hospital. Chart review has become a snap. All labs and orders are at my finger tips. We keep paper backups for when computers are down but that rarely happens anymore.

allnurses Guide · Nov 5, 2005

We've only gone to computer charting for meds . . . .and it is Pharmtrak, a very difficult and slow system that frustrates the heck out of the nurses.

I can write faster than I can chart on the computer.

steph

DutchgirlRN, ASN, RN · Nov 5, 2005

I love computer charting. Everything is a check off. Nurses notes are strictly charting by exception. A great time saver and nurses notes are still there to document anything important.

NNEKA RN · Nov 5, 2005

Well so far at my hospital it has worked really well. I guess because we still have the paper charts and we are able to write narratives in the chart. However we use LASTWORD, and it is really great. We are also able to type our narratives in also. The Doctors love it, the Nursing Assitants are able to access a certain area to chart their documentation also.

Also, the daylight savings time was no problem at all. A lot of hospitals in my area are switching to the computer system. Though i have to admit that some programs are cubersome than the others.

My advice to the OB nurse is "Please make sure you have documented everyhting that you are supposed to. cover your self". Also keep a little notebook for your self regarding the daily happenings.

Let the Company worry about the system going down......:)