Computer Pre-Charting

[ashifer22]

Acceptable or not? With our computer system you don't technically "sign" the chart until the end of the case, so is it wrong to prior to a case charting basics such as who will be in the room, what kind of anesthesia it is, wound class, where the pt is coming from and going to, what the serial numbers for the bovie is, etc? Times when you are pressured for a quick turn over or the case will be very fast and you have a bit of time before the case starts, why not chart those misc items? Just wanted hear thoughts from others. Thanks.

[SandraCVRN]

We prechart , esp for short cases if we have the chance. I don't think there is anything wrong with charting who is in the room, equipment and the like.

I don't prechart counts or anything timed.

[lockheart678]

I know a lot of people I work with pre-chart, but when I was on orientation, one of the nurses I worked with told me never to do that because it would look bad if that chart ever ended up in court. Even if it is on the little things, that computer will still record when the screen was filled out, and if those pages of the chart were filled out before anything was done, what else might be charted that wasn't done (yet)? That was something that really stuck with me, so my philosophy has always been to never chart something unless it has been done. It may take me an extra couple of minutes to finish up my charting at the end of a case, but it makes me feel a lot better knowing that I'm charting something that is true because it has already happened.

[Rose_Queen, BSN, MSN, RN]

We have preset defaults that we can use for the most common cases, and they are surgeon specific. With the system we use, there is a way to get around the time stamp- we just don't hit the save button. With the defaults, basically the only things we have to fill out are staffing and times.

[Heogog53]

My hospital prohibits pre-charting because of the way our system works. Once the patient is in the room, then the case can be opened. If you open the chart ahead of time and the case is cancelled, then you have to tell the whole wide world that you messed up. It is tied into our billing/charges area. The other issue is opening the chart before the patient is brought into the room and the patient comes in and for some reason anesthesia aborts the case before anything else happens, the time the chart was opened is examined in our stats gathering.

Either way, you get a Big Girl(Boy) Verbal Reprimand for doing it

[lilla_fjaril]

I prechart as much as possible. I even prechart counts, drains, dressings, etc. If we didn't do this we'd never be able to complete the whole chart on short 1 hour cases. We don't have to put times in for most things so I just delete times for everything I prechart. my thought when I chart all the counts as correct and 2 chest tubes etc. is that is the way it is going to turn out. And if some reason the count is incorrect I'll have to file an incident report, so there's no way I'll forget to go back and change the chart. I'm an orientee so I checked with my charge first to be sure it was okay, but once I got the greenlight I don't hold back. it's all about efficient use of time. Check your hospital policy and then do whatever is compliant and works best for you.