computer or paper charting? what program do you use?

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Specializes in LDRP.

I am new to ob from cardiology. There, it was mostly paper charting, with the med charting on computer (mak) and of course, pyxis to withdraw meds/witness wastes, etc. all assessments, admission database, vitals, nurses notes, i&o's written down.

now in OB, its all computerized and i love it. everything is on the computer and linked! i can go back and look at the stored EFM strip on teh computer, and it has notes as to where i put anything in-vitals, nurses notes, procedure, etc. i am in love!

so, do you do paper or computer charting? what computer program do you use?

funny thing is, i always used to think i'd hate computer charting (that comes from my student nurse days at a hospital that used meditech. that was evil stuff there)

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The hospital I work at is a bit unique. We have a combination of paper and computer charting. Assessment, hourly vitals and "significant" events are charted at the bedside. Nurses who work dayshift write a daily note in the patient chart, other significant events can be written in the chart as need be (at any time). Physician's still hand write all their chart notes. Everything else is done via a computer program that was originally developed by the hospital in the 90's.

It's a dinosaur of a system, a DOSS driven hodgepodge and endless maze of commands. For example: to chart off scheduled medications I have to enter my password and then click on 3 different categories/links in order to find the scheduled meds to check off (and that's one of the simpler procedures, putting in orders for the physician's is another story). Patient labs and diagnostics are found under a different computer program (with a different password) also Doss driven (using F keys to move forward and backward, etc).

When I was a student (graduated 8/05) I had opportunity to see the charting systems of several area hospitals. One in particular was completely computer driven and paperless. They had a great charting program (that I can't remember the name of!), it was so easy and the best part was . . . all the notes where type written . . .I could actually clearly read patient past history/illness . . .it was wonderful.

I'm in the midst of transferring to a new job at a different facility. One of my questions during the initial interview was if this facility uses the same computer program(s) as the main campus where I now work. The answer was no (whew), so I'm looking forward to perhaps using a newer, more user friendly charting system in the near future!

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Specializes in OB, lactation.

Our hospital just started using Cerner (but I've heard it is not the complete version) - MD's still write orders, notes, etc. I think that is supposedly going to change at some point in the future.

We admit pts into Cerner but use Watch Child for most labor documentation, and switch over fully to Cerner when they deliver and become pp pts. I think we are supposedly making them merge or getting something compatible in the future (not holding breath).

There are some things about Cerner that bug me; a lot of things don't cross over and we have to do a lot of double documenting. It would also be a lot easier if we could default some things to stay on that are always going to apply to your area and just change them for the 1% of the time when they don't apply, instead of having to sit there and click the same things every time. Also, sometimes things that could take one click require several steps which is an annoying waste of time. Logging in also seems more time-consuming every time you go to a computer than it should have to be. All that said, I don' t think the computer thing is some big horrible deal like some people think.

In my clinicals I used Meditech and Clinicomp, which were more DOS-looking programs; Cerner appears more "Windowsy" tho I don't think it actually is (?).

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We use the QS system, and it's all I know so I love it.

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Specializes in LDRP.
We use the QS system, and it's all I know so I love it.

us, too. i also forgot to mention that the doctors written orders and progress notes, etc are all written in a hard chart. they dont have computer order entry yet. the secretary still has to decipher their handwriting.

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:nurse: Our hospital just started using "Care Cast". We were trained in March but didn't start using it until June 1st. I chart all my wound and ostomy notes on the program and I am able to read the Physicians History and Physicals without leaving my desk. The Doctor's orders are hand written and there are no body diagrams to mark wounds on so those are the two things I don't like about it. The big thing is my carpal tunnel doesn't hurt so bad by the end of the day because I'm not writing!
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Specializes in Ortho/Neuro.

There are some things about Cerner that bug me; a lot of things don't cross over and we have to do a lot of double documenting. It would also be a lot easier if we could default some things to stay on that are always going to apply to your area and just change them for the 1% of the time when they don't apply, instead of having to sit there and click the same things every time. Also, sometimes things that could take one click require several steps which is an annoying waste of time. Logging in also seems more time-consuming every time you go to a computer than it should have to be. All that said, I don' t think the computer thing is some big horrible deal like some people think.

We also use Cerner and I hate the silly double documentation!!!!

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Specializes in L&D,- Mother/Baby.

We use QS but the Dr.s still write on the hard copy. Until about a week ago, we used QS for mother and baby, from admission to discharge. Some of the Pediatricians complained that the printed copy was difficult to follow and I must admit, the flow is no great...so now we do only the admission information in the computer and hand chart everything else on the baby.

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OB is still all paper charting for the docs and nurses. And I'm glad!

We have an awful program, PharmTrak, that we use for our meds on the acute side. It is slow, slow, slow.:nono:

I like that I can just chart my meds in OB on a piece of paper - it is right there, handy . . . and I don't have to wait for another nurse or the ward clerk to get off the computer so I can chart my meds. Heaven.

steph

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Specializes in L&D,Wound Care, SNC.

We went live with OB Trace Vue this past March. Once I got used to it I fell in love with it. There are somethings I don't like, we don't run paper strips anymore so I can't write things on the strip such as medications, sve's etc. It is great when working out on the floor. I now work in our recovery room and when I go to pre-op the scheduled sections it takes forever to enter all admission information if the patient has never been to triage. Paper charting was so much quicker in that instance. However, don't take my computer away!:no: I can type so much faster than I can write.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Labor charting is done on paper flow sheets. After delivery, all patients are charted on MEDITECH which I HATE. Don't get me started.........

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Specializes in ED, MS, CC.

We use Meditech at our hospital and we have "stingers" computers on wheels that we take into the pt's rooms. It's great. Our blood sugars machines download into the system and so do our dinomates! I guess it's a good thing since they haven't taught us any charting in school.

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