Documenting

All of our documentation of medications is on the computer now. We have to scan our badge to get into the medication list and then to chart giving the meds we have to scan each medication and then scan the patients ID badge. We still have a printed list of medications in the patients chart as a back-up in case the system goes down. It helps with the "rights" of giving medications... if you scan things too early or too late, the wrong medication or the wrong patient, etc you will get error messages. The program has prevented a lot of medication errors. I know for myself, it has saved me a few times!!

I've seen it both ways. Some hospitals have paper charting, some have computer charting. I've been in two hospitals that have a mixture, computer documentation , but paper medication administration records.

We still have hard charts in which the doctors write their progress notes and orders. The orders are put into the computer system by a ward clerk or the nurse. The orders in the computer are checked against the paper chart by the nurse. When giving medications, we chart them in the computer. We do not use scanners, and I hope we never do.

As far as documentation goes, we have to chart our head to toe assessments, nursing interventions, IV assessments, pain assessments, and patient teaching. This is all done in the computer.

When giving medications, we chart them in the computer. We do not use scanners, and I hope we never do.

I used it for the first time last night. And although I had a nurse standing right there to walk me through it, I feel it really isn't that bad of a learning curve as long as they are using the same system that you are used to. We are using Medi-tech, and you just highlight the med on the screen you are going to give, scan the actual medication (they all have bar codes on the packaging), then scan the patient's armband. Now granted, it worked perfectly last night, and I had someone right there walking me through it, but I have heard stories about how the med won't scan and how irritating that is. I'm sure there is a work around. Nurses seem to be very innovative when it comes to getting their patients taken care of in spite of everything the system throws at them.

We just started using scanners, and I like them a lot. It charts the med after we scan it in the patient, and it reminds you to give a partial dose, or if the medication has been discontinued, etc. Sometimes, the day shift nurses don't take the meds that have been discontinued off the Kardex, so it's nice to have another system to prevent errors.

My facility is changing to all computer charting this coming Sunday. I'm ICU and am going to miss the flowsheets...and Kardex..