Document or die?

allnurses Guide · Jun 25, 2017

Yes, it is possible to computer chart on that many patients, very much so.

It just may take some time.

You can always write down your assessments and other findings on paper,

take notes on your patients, and then transcribe them to the computer,

at least until you get more used to charting directly into the computer.

A lot of people probably do that anyway.

Calm down. :) Like so many things, it may seem difficult at

first, but once you start using this charting system and really

get going, you'll probably forget all about a time when you

didn't have a clue what you were doing. :)

tyvin, BSN, RN · Jun 25, 2017

You'll have your COW with you. I dispised handwriting nurses notes. When the computers came out that was a dream. You need to brush up on your keyboarding skills/typing since you say you're computer savvy it must be the keyboard.

There are many free keyboarding programs online or take a class. The software will come to you. Which part are you having concerns with...the typing or the software?

I say Aloha to pen and paper. Typing is so much faster and if you get your routine down you'll get it. What program is it? Reminder; never leave your computer open with your login open. Never look at any chart that's not assigned to you. The main thing about documentation is that's how your facility gets paid. You need to know how to document for that.

Transcriptionist??? Pay attention in class. You're not transcribing; you're documenting on your patients. 5 or 6...if you're lucky :) (just joking, but not really...). Try not to blame your school. You say you know your way around a computer and that's all the programs are...software for documenting.

It's all about time managment. If you think it's going to be impossible; than you shall have your wish. Get positive about all this (just my advice). If you're not typing correctly it can slow you down since you need to look at the keys instead of keeping your eyes on the computer screen when typing. I know; I've seen many two finger people just blast their way through a paper but it's so much easier the other way if you haven't taught yourself your own method IMO.

Good luck to you :)

Editorial Team / Moderator · Jun 25, 2017

I worked in an ED where a 5-patient load was our standard, and we documented on all of them quite successfully. With bed turnover, this was many patients per shift. You'll get there, it can be done!

RNperdiem, RN · Jun 25, 2017

I have done paper charting and computer, and to be honest, paper is faster if the flowsheet is well designed. Those days are over so we must adapt.

Charting as you go has worked for me. Not getting behind early in the day was important. Once all patients were assessed and the first round of morning meds were all charted, the rest of the day would go well.

cleback · Jun 25, 2017

I would feel the same way about paper charting if I were asked to do that now. Honestly, you'll get used to it. And orientation is just an introduction... you'll need the practice on the floor to feel competent. (As with most things nursing). That's probably all she meant. Take a deep breath--it'll be ok.

yarrumzil · Jun 26, 2017

Thanks! I know that a nurse is more than a transcriptionist. I know it's not impossible! I was feeling so overwhelmed about it all. Thanks for the encouragement. I can do this! I will not let the computer software defeat me.

anitalaff, BSN, RN · Jun 26, 2017

You'll have your COW with you. I dispised handwriting nurses notes. When the computers came out that was a dream. You need to brush up on your keyboarding skills/typing since you say you're computer savvy it must be the keyboard.
There are many free keyboarding programs online or take a class. The software will come to you. Which part are you having concerns with...the typing or the software?
I say Aloha to pen and paper. Typing is so much faster and if you get your routine down you'll get it. What program is it? Reminder; never leave your computer open with your login open. Never look at any chart that's not assigned to you. The main thing about documentation is that's how your facility gets paid. You need to know how to document for that.
Transcriptionist??? Pay attention in class. You're not transcribing; you're documenting on your patients. 5 or 6...if you're lucky :) (just joking, but not really...). Try not to blame your school. You say you know your way around a computer and that's all the programs are...software for documenting.
It's all about time managment. If you think it's going to be impossible; than you shall have your wish. Get positive about all this (just my advice). If you're not typing correctly it can slow you down since you need to look at the keys instead of keeping your eyes on the computer screen when typing. I know; I've seen many two finger people just blast their way through a paper but it's so much easier the other way if you haven't taught yourself your own method IMO.
Good luck to you :)

Please reread the OP.

anitalaff, BSN, RN · Jun 26, 2017

I have the same thing with visiting nursing. The software is a nightmare and the follow up paperwork is not integrated. I spent 4 hours after work trying to get it all done on my first day. It is so stressful, but bit by bit, I am learning how to navigate. It's not about being computer savvy, it's just about learning the quirks of a specific system. Don't try to figure it all out alone if you can help it.