Skip to content
View in the app

A better way to browse. Learn more.
allnurses

A full-screen app on your home screen with push notifications, badges and more.

To install this app on iOS and iPadOS
  1. Tap the Share icon in Safari
  2. Scroll the menu and tap Add to Home Screen.
  3. Tap Add in the top-right corner.
To install this app on Android
  1. Tap the 3-dot menu (⋮) in the top-right corner of the browser.
  2. Tap Add to Home screen or Install app.
  3. Confirm by tapping Install.
Discussion

Document or die?

Starting my RN career in med surge at a safety net hospital right now. I had clinical on the floor and loved the busy pace and diversity of the patients.

I have been more excited than scared of working until we went over the software for documenting. The thought of having to electronically document 5-7 patients is very overwhelming. In school we hand wrote our documentations and I feel like it has crippled the start of my career.

I consider myself computer savvy and literally almost cried in orientation. The new ICU nurses in orientation were telling me they felt sorry for me for picking med surge. The lady teaching the class gut laughed and said "o this (orientation) won't be enough for you."

If other nurses can do it so can I.

I guess I just want to ask how the hell can a nurse possibly take care of 5-7 patients and document? Is it even possible to correctly document patients in the computer systems? Do nurses just pray someone doesn't try to sue them because they didn't click the right check box? Do med surge nurses spend the majority of the time being a transcriptionists?

  • Quote

    • Featured Replies

    • Guides

    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. :)

  • Quote

    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 :)

  • Quote
    • Moderator

    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!

  • Quote

    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.

  • Quote

    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.

  • Quote
    • Author

    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.

  • Quote
    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.

  • Quote

    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.

  • Quote

    • Join the conversation

    You can post now and register later. If you have an account, sign in now to post with your account.

    Guest
    Add a Comment
    Go to topic listing

    Currently Reading 0

    • No registered users viewing this page.

    Account

    Navigation

    Search

    Search

    Configure browser push notifications
    Chrome (Android)
    1. Tap the lock icon next to the address bar.
    2. Tap Permissions → Notifications.
    3. Adjust your preference.
    Chrome (Desktop)
    1. Click the padlock icon in the address bar.
    2. Select Site settings.
    3. Find Notifications and adjust your preference.