Critical care charting via computer

cruisin_woodward · Jun 8, 2009

Most of our assessment stuff does carry over... There are some fields that do not... I like it

trixie · Jun 8, 2009

Our charting does not automatically carry over for shift assessments. In most fields, the nurse CAN hit a button (f5) and it will recall the previously charted information. I am not sure how often this is used, but I would suspect a lot. :uhoh3:

I can selectively block fields that we will not allow them to recall info. I specifically use these a lot in comment boxes, as I found nurses were just mindlessly copying the same comment over and over again. This was especially annoying when the comment contained a spelling error! I also thought it would be a red flag to a lawyer in a lawsuit that the same info was written in the same exact way in the comment area.

You will always have a few who slack on the work and just copy whatever the nurse before them put down. This happened on paper, also, so it is not a computer specific issue.

Texas Tornado · Jun 8, 2009

We don't use that same system, but one that shows what the previous nurse charted and gives the option to click the same thing.

Pro's - nice b/c a lot of stuff stays the same. I also have learned a lot about charting from seeing what other nurses have written and how they worded it. Frankly we all pick up on different things and it is helpful to see what others have found in their assessments.

Con's - people get sloppy and just click what the person put in before them. I've see people click on stuff from my assessment that I know had changed even before my shift was done, and in a hurry it is tempting to rely on what others have assessed.

We will be changing over to an entirely new system soon that will not have this option and I must say I'm sort of dreading it. Reason being a lot of "little" stuff does not get passed on in report that is good to know if this is baseline or a change.

Good luck with whatever you decide.

Reno1978, BSN, RN · Jun 8, 2009

I don't think it's a good thing to let one nurse basically copy another nurse's charting. For floors that require more than 1 assessment for shift, I agree with being able to copy YOUR OWN documentation and make adjustments as necesary.

At my old employer, you were able to carry forward other's charting, and while it was frowned upon, I would constantly see my charting selections, verbatim throughout the following shift.

For example, I chart assessments at 20:00, 00:00, and 04:00. I D/C a central line at 05:45, and document it then, but then the dayshift nurse copies my charting and doesn't make any adjustments and documents all day long that a patient has a central line at 08:00, 12:00, and 16:00...

I think you should only be documenting your own assessments.

CampinRN · Jun 8, 2009

We use an antiquated program that doesn't scroll or have decent drop-down menus that apply to our unit. Once something is charted, it would be nice to chart by exception from that point on -- not copying with an F key, but keeping the care consistent. (For example, it makes us reinput equipment that the patient uses every day.) And don't get me started on dates of IVs, dsgs and tubing disappearing.... :nono:

loriangel14, RN · Jun 8, 2009

Our charting system has a recall button that brings up the previous charting on most interventions, not just assessments. We are supposed to read and edit appropriately but I would bet many do not. I do like it if it is a daily assessmentand I have had the same pts 3-4 days in a row. I can review my own charting quickly but if it is someone else's I am more careful.

blueheaven · Jun 9, 2009

We use a computer based system where assessments can be carried over from one shift to the next. I don't like the idea of nurses being able to carry over my assessment to their shift. Even new IV starts will default over. Maybe if the system had a way to "lock out" the previous shift assessment from defaulting over would be a good idea.

Some people don't monitor their IV fluid carryover/Piggybacks and so at the end of a 24 hour day, it will show that the patient had 9000 liters in! Then I get to go back through the IV portion and delete the misappropriated fluid while the nephrologist is standing there rolling his eyes.

The other thing I am concerned about is when other nurses don't pay any attention to what is coming over and not changing wrong information. For example Joe Puffer's O2 sat shows up @ 8am as 63% and he had his probe off his finger. Lazy Lolanda doesn't bother to change the sat in the computer (she did go in the room and check the pt). What happens if someone does NOT change the assessment? I see legal issues galore!

RNKel, ASN, RN · Jun 9, 2009

We use Soarian and we can carry over our previous assessment info (only our own), but you still must go in and chart integumentary findings again. You click boxes next to each area (neuro, resp, cardio, etc) that says there were no new findings since the previous assmt.