Computerized nursing documentation

[sufernan]

Hello All,

My workplace is in the process of transitioning from paper to computerized nursing documentation. We already had computerized documentation (CD) for vital signs, medications, worklist, IV care, I/O. The main focus now is on CD for daily nursing assessments. They are doing it system wise and 1 -2 systems at a time. In my opinion, its moving too slow!! My question is, what kind of program do you use or used at your hospital for daily nursing assessment computer documentation? We currently use CareCast.

[Lucky724]

Don't know anything about your system..I've used several..Meditech..Greenway..Care Anywhere...once you get the hang of it it's not so bad.

[NotMyProblem MSN, ASN, BSN, MSN, LPN, RN]

I've used Meditech, Cerner, and currently use McKesson. But the paper charts NEVER go away. Before, we had to do the chart checks. Now we have to do the computer checks to make sure that what's on the computer is on the chart and what's on the chart has been entered into the computer.

I say ENJOY the slow transition while you can! For us, it has been added work and is a nightmare when, at the end of the shift, we're trying to do our checks to make sure everything has been carried out and entered and the doctors have come and grabbed the charts. It's a nightmare when some doctors enter stuff on the computers and other doctors still hand-write orders and progress notes because management is not enforcing the fact that we ARE computerized and have been for the past few years.....supposedly.

It's very frustrating when you get a phone call while in a patient's room or even just down the hall regarding a question about something and the information that you need is never available on the resource at hand. It's not on the computer so let's go back up to the nurse's station and check the chart. Or it's not on the chart so let's see if we can find a computer that's not in use and check that.

[samchloe]

We went live with Soarian Clinicals last April. Our soarian includes CPOE and nursing documentation. We are on computerized medication admin for 7 years. The only thing i would say, there is no perfect system. All Clinicians should be watchful for whatever it brings for patient safety.

[MendedHeart]

I have worked with soarian and cerner. They are ok..I dont prefer one over the other ..just different...We are about to transition to Epic..hope its good. My job is transitioning to almost paperless. We are entering orders in directly now versus writting them.