Computerized Documentation Poll

JR816, BSN, RN · Feb 27, 2006

1)In your opinion, what are some advanatages of computerized documentation?

I think that computerized documentation allows the nurse to be thorough and sticks to a strandard baseline of information.

2)In your opinion, what are some disadvanages of computerized documentation?

One downside is that technology isn't always in perfect working order. When the system is down, you have to wait for someone to fix it and in turn your patient may need their med's (which might not be accessible) or you might not be able to access some of the labs and things.

3)How do you feel computerized charting can be improved or implemented better?

I do my clinicals in a facility that does computerized charting as well. As a student, I think it's awesome. It prompts you to cover all of the bases. It allows you to referance the previous nurses charting for comparison.

4)Do you feel going completely "paperless" is a sound idea for hospital charting?

I can't really answer this question. I don't feel that I know enough about legality issues and computers. :uhoh3: :uhoh3:

I hope I helped out a little. Good Luck!!!!

Gompers, BSN, RN · Feb 27, 2006

1)In your opinion, what are some advanatages of computerized documentation? No more fighting over the paper chart - multiple staff members can be viewing the same patient's computerized chart at the same time from different locations in the hospital. Bad handwriting becomes a moot point. You can actually read your orders and others' assessments, etc. MAR is very nice to be on the computer. Correct medication dosages and lab ranges are right there next to the patient's information. The neater things are, the less likely there will be mistakes or omissions.

2)In your opinion, what are some disadvanages of computerized documentation? Some people don't want to learn computers and complain a lot. There can be typos. Honestly, very few cons in my eyes.

3)How do you feel computerized charting can be improved or implemented better? Get rid of paper charts completely. Right now, we still put some things in the paper chart and give report off paper printouts. MIght as well go completely online so there is no wasted paper.

4)Do you feel going completely "paperless" is a sound idea for hospital charting? Yes. It is much easier to go through a patient's chart on the computer, IMHO. It's all right there with the click of the mouse. I think, legally, it's a good idea too. Not only can you read what others have wrote and what the docs have ordered...but in court, everything is very clear. I can barely read my own writing sometimes - if I was ever in court, it'd be nice to have everything typed rather than handwritten.

Katnip, RN · Feb 27, 2006

1)In your opinion, what are some advanatages of computerized documentation?

Legibility. No more trying to decipher someone's handwriting.

Dileanated spaces to put charting for different categories. No more thumbing through paper pages trying to find the nurse's note among all the other disciplines who often skip pages or parts of pages. Nursing notes are in one place and easy to find.

Standardization. Assessments follow a standardized format, are easy to access quickly. The format is good as a reminder that so-and-so patient needs a follow up on pain assessment, or vitals when you're extremely busy.

2)In your opinion, what are some disadvanages of computerized documentation?

Not all units in a hospital use computerized documentation. Different disciplines use different documentation software. Example: our pharmacy, radiology, respiratory, and nursing departments all used different software which were not accessible to other deparments.

Not having doctors write orders on the computers.

Often there is repetitive charting when a unit has not gone completely paperless because there is no uniformity between disciplines, and docs aren't using the computer charting.

It is a problem when systems are down for power outages or maintanance.

3)How do you feel computerized charting can be improved or implemented better?

As stated above, all disciplines should be using the same format that can be accessed by all. All units in a facility should use the same type of software.

4)Do you feel going completely "paperless" is a sound idea for hospital charting?

It's better for storage and retrieval purposes. Not to mention safety and privacy. As long as there are reliable offsite storage facilities for back up. However there is a risk, no matter how small of hackers getting into the system.

jessnurse05 · Feb 27, 2006

1)In your opinion, what are some advanatages of computerized documentation?

I agree with other posters that legibility is a big plus to computer charting. I also like that it prompts for things (I often forget to ask the pt about last bm, but the computer asks for it). I also like being able to look back at the last person's charting. Labs and other test results are so much eaiser to look at, also there is a feature where we can look at a trend in a specific labs so if you have a critical you can tell right away if it's better or worse than the last one.

2)In your opinion, what are some disadvanages of computerized documentation?

There is an option on our computer to write nurses notes, but the doctors don't see the notes, so last week when my pt refused her daily wt, I wrote a note, but to the doc it would look like it just wasn't done. There isn't always an option to add a comment when charting something really abnormal, and like I said, the nurses notes don't show up with the rest of the information.

3)How do you feel computerized charting can be improved or implemented better?

My facility has just recently, in the last few months, switched to computer charting. I think there needs to be a consensus with the educators about what the best way to chart is. Some say to use nurses notes, others say that you should never write notes, you need to add extra interventions to the care plan. I think it's necessary to make notes sometimes, especially for things like restraints, instead of just filling in the yes or no boxes. I want to have a clear narration of what the situation was, and why it is best for the pt, instead of just saying that they were pulling tubes or getting OOB.

I'll be happy when the MD's start using the computer to write orders, right now those are still on paper.

4)Do you feel going completely "paperless" is a sound idea for hospital charting?

We just got rid of our paper Kardexes, so we just check the new orders with the current MAR, then check old to new MAR's. I have only seen one error resulting from it, but I think there is a possibility for some major errors because if one nurse misses an order, it most likely won't get caught with this system.

Jessica

Editorial Team / Admin · Feb 28, 2006

1. advantages: accessability (chart is accessable from any terminal, plus is accessable to several ppl at once; all reports are accessable: labs, radiology, etc), legibility (for legal purposes!), clarity, standardization of charting, good for prompting, thus actively encourages more thorough charting.

2. disadvantages: having to keep signing on again and again d/t mandatory "sign-off" after a pre-set period of inactivity (i understand the rationale behind this, but i work in a cath lab, where no one but me needs the computer, will be looking at it, etc, and i have to sign on several times during one case, just to chart); not enough terminals (given the amount of ppl who need to access the chart [during the day, at least]: dietery, pt, ot, social workers, case mgrs, mds, students, nurses . . .);

3. improved or implemented better: lots of inservice before implementation, plus lots of support after implementation, which is when one really learns the system, and real-time! possibly over-staff the first few days of implementation, as ppl will be trying to do their regular duties/tasks, plus work through the learning curve (at least, have support personnel available 24/7 while in transition to new system). make it simple! those who write the programs, please don't make me have to open ten windows just to get to the screen i need!

4. is going paperless a good idea?? i think so, but have a good back-up paper system in place and readily accessable, in case of power outage, disaster, other unforeseen problems. what if the lab system crashes, what will you do for the next 3-4 hr for your labs??