Ahh, this week I have had what seems like my 10th disagreement this semester with a clinical instructor about charting in this hospital's new computerized system (EPIC). I am starting to feel that some nurses who are accustomed to paper-based charting are confusing matters with computerized charting, but maybe I'm wrong. I start to get nervous when I'm asked to "click, click, click" while charting an assessment. I feel like computerized charting as a rule sort-of tries to put words into my mouth (computer wants a one-word description or a yes/no answer, and I want to write "O2 sats in the high 90s when patient is awake. While asleep, sats fall to mid-80s but rise when patient wakes up." The computer wants a sat number and what time that number was taken. Anyhow -- point is, I feel like the computerized system already is taking away some of my better charting judgment.
Add to that how easy it is to document that about 50 pieces of assessment data are "WNL" and I get really anxious. The other day I had a patient who was admitted for pneumonia. The standard/ordered assessments did not include a full neuro or hearing/vision check. My instructor called me over to "correct" my charting because I left the neuro portion blank, and I did not say his vision and hearing were WNL. I hate WNL. You can click on what it means to say "WNL" and it gives a litany of things that you are agreeing to by saying your patient is "WNL" in that area. I am not comfortable charting a patient's neuro status is "WNL" nor that his vision and hearing are "WNL" unless I have checked all those things. And if I've checked them, I want to chart something more descriptive than WNL!
The instructor said "Well, do you think his hearing is fine? Does he demonstrate any hearing problems?" I asked her if she wanted me to assess his hearing and vision and chart the specifics of that assessment, and she said to "just ask his him if he's having hearing/vision problems." Okay, but then I'm thinking the only thing I'd feel right charting after THAT is "Patient states he has no hearing or vision problems." I still don't think I should chart WNL until I've done a vision test, or a hearing test, or whatever.
Just because it's there on the computer screen and I can easily check "WNL" doesn't mean (in my mind) I should do that. It seems to me that it would be better to not chart anything about neuro if you didn't do a neuro assessment, than to say "WNL." Obviously, if neuro checks are ordered, or if you are concerned about the status of a particular system, you would definitely need to do a complete assessment...but these flowsheets in computerized charting have an endless number of things you COULD chart on...doing full assessments in those areas would take an eternity, but charting that they are "normal" seems to me to be a bad idea. I'd prefer either to be descriptive or leave them blank...anything else feels a little dishonest to me, but I've been known to be a little overly literal, so I wonder if I'm wrong about this...
I don't know any charting system that doesn't give you the option of making of your own comments. It's actually terrible and legally wrong to leave a particular section of the charting BLANK. Regarless of what unit the pt is admitted, a systeme by system pt's assessment is required. So, a pt may be admitted for a hip fracture, you still need his/her neuro, resp,...evaluation, not just a musculo skeletal or cardiovascular.
nfdfiremedic, that helps a lot, actually. And that phrase would fit in the "piece of paper icon" note. Or, if I was going to write a longer note, I could write there "refer to Nursing Notes @2200" or something. EPIC is new where I am, and people all use it differently. As a student nurse, this gets confusing for me because I'm not sure what's individual preference, what's institutional preference, and what's just crappy charting. :)
MoisesRN, I don't think it's legally wrong to leave a section blank. It would be fairly impossible to fill in every single computer blank in a 12 hour shift. :) In the paper charts, there was a 2 page sheet with brief neuro parameters, brief ears/nose/throat checks, etc. In the computer charts with EPIC, depending on how the hospital uses this system, you could be looking at pages and pages of potential assessment areas. I don't know any nurses who do a FULL neuro check, a full hearing/vision screen, etc. for every patient every shift. They do the brief "can you feel this, can you push against my hand" -- maybe a pupil check and make sure that the patient talks, listens, etc. That was sort-of the point of my post...you have infinite fields to assess when you're dealing with a computer rather than a piece of paper. And it seems to depend on hospital policy, like I said. Some units have a specific flowsheet per treatment or diagnosis (a one-day post-op total hip; a first-time mom; a peds patient with a respiratory problem). Other floors, and other instructors (like I was talking about) seem not to be consistent in what data they want.
I've used EPIC for a little while now, and we do a "Shift Summary" at the end of our shift. So if something is going on that the free text area on the flowsheet doesn't give me enough characters to address, I just put in "see shift summary" and go into greater detail there.
EPIC does take some getting used to as far as all of the features go, and honestly as a SN I doubt you'd get enough time with it to learn your way around it's quirks. On our version, what's considered WDL is very straightforward and fairly limited, and we only do more in depth assessments of a particular system if ordered by the physician or if prudent given the pt's diagnosis list.
So for a pt who is young and in for new-onset seizures, we might never specifically address edema. But for a pt with a history of CHF with a recent exacerbation, it would be entirelt appropriate to select to add both lower extremities and chart "none" if that's the case. EPIC is actually very flexible and fairly user friendly once you've spent enough time with it, but it can be a difficult adjustment if all you've dealt with previously is the paper world.
Specializes in CCU, CVICU, Cath Lab, MICU, Endoscopy..
It's actually the legal side I'm concerned about so thanks for bringing that up! I think it's easy to think checkboxes eliminate confusion, but humans are complex entities with issues that need more than a yes or no. Thanks for everyone's input! I need to
do what feel right to me, bottom line, and that's being as descriptive as I can be with the time I have to chart in.
LOL....we use EPIC I didn't like it at first but it grew on me. However. So much repitition! If I am unable to describe it on my assessment, I add it on careplan or flowsheet notes. To avoid legal issues my hospital expands on every assessment whether its wdl or x. Can be annoying but so far its working. Good luck.
MoisesRN
12 Posts
I don't know any charting system that doesn't give you the option of making of your own comments. It's actually terrible and legally wrong to leave a particular section of the charting BLANK. Regarless of what unit the pt is admitted, a systeme by system pt's assessment is required. So, a pt may be admitted for a hip fracture, you still need his/her neuro, resp,...evaluation, not just a musculo skeletal or cardiovascular.