documentation

[sunrock]

Could some please share your experiences when you were introduced to computers after working with paper documentation for meds., and did you make many silly errors, and the outcomes.

[Silverdragon102, BSN]

Moved to the general nursing discussion forum

[tokmom, BSN, RN]

We just moved this year to bedside medication verification and love it. Yes, it's time consuming to scan instead of just giving a med, but we have a near zero medication error rate. Our errors come from people hanging antibiotics and not starting the pumps! It was tough to get used to, but I like the fact I can go home and not worry that I overlooked a med.

Now we are computer physician order entry, and that's been rough. Those dr's are trying, but Ai yi yi!

[nurseraphael]

Our hospital changed to EMAR (electronic medication administration record) last year. There was a lot of grumbling and whining prior to and during the transistion by both old school and new grad nurses. we went through the bumps and now I cant imagine what it must have been like back in the dark ages of transcribing medications / yellowing them out / understanding other nurses scribbles on the mar . . . the record is straight forward . . clear communications - the next phase is physician order entry. No more calling the doc at 0000 to ask what he wrote in the admission orders.

While scanning takes extra time, it saves time all over the place. no more looking through 16 pages of a mar to find the medication you forgot to give 4 hours ago. it is easier to schedule 3 antibiotics treatments so that they only overlap once a day.... and you can see the medications given to a patient over the last 24 hours when they are transferring in from another unit at a glance.

It was the best move our hospital has made in the last year

Just the other day the picis machine opened the wrong drayer and I blindly removed the med (i was in a rush) when I scanned the med it told me that the medication was not profiled! Do you want to profile _____? oops - error caught before reaching patient. We all make an occasional mistake - this helps to prevent that

[Ruby Vee, BSN]

i've been charting on the computer since the mid 90s. i was opposed to it at first -- the competition for the few computers in our icu was fierce with nurses, rts, physicians and pts trying to chart. it was miserable. the learning curve was miserable. then our hospital sprung for computers at the bedside and computers attached to the wall outside of every other room. physicians were warned to stay off the bedside computers, physicians had their own in the call room and in their office. the wall computers were up for grabs -- rt, pt, consult services, etc. suddenly it all seemed to go ever so much more smoothly . . . and now that i'm used to it, saves a lot of time. getting used to it, though -- i shudder to remember!

if your hospital or unit goes live, an adequate number of computers to start with is key. and on go live day -- and for the next 10 days or so -- plush staffing and superusers with the software. it's miserable to try to code your patient and document in brand new software at once!

[sunrock]

Thanks for the response, i did not have enough inservice and hence out of ajob, lesson well learned.