e-charting and policies

rninformatics, DNP, RN · Nov 9, 2006

See below - copied with the sender's permission from a private e-mail message I recieved.

Angela

Wow!!!, what a small world!!! I've implemented 10-12 different vendor products in 8 different facilities and it just happens that I was the Project Manager responsible for Building, Testing, Implementing and Evaluating Keane at a pediatric hospital here in Chicago!! Where are you located?

Yes it is a small world indeed!!

My primary suggestion for assisting the staff in charting real time is just "do it". I have had this issue come up in every clinical setting - from home health to ICU to the Med Surg Unit to Radiology. Get in the habit of charting as soon as you render the care/perform the intervention/ complete the assessment, etc.

Cut yourself some slack though and realize that you will not be able to do this 100% of the time. I'm not endorsing charting hours after care was actually rendered but within reason. Shoot for a realistic goal of 70-80% and document in as timely a manner as possible. I've been an RN for 20 plus years and I too have had to document "after the fact" as there is only one of me (Thank God!, LOL) and I have not figured out how to provide care while at the exact same moment document that care. Remind Administration that the only realistic way to have your staff chart as close to 100% exactly when care is provided is to have a ratio of 1 pt. to 1 nurse.

In short, do your best and cut yourselves some slack.

Hope that Helps!!!

Angela

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Re: e charting

Quote:

Originally Posted by suni

Do you have any websites with recommendations for documentation with echarting. We just switched over to e charting and we are having a little trouble charting in real time with all our post ops. Our system is Keene. Each section has checkboxes and then at the end of each section is a comment box pertaining to the system assessment.At the very end is a page for additional notes, we also have our careplans online and we update them every shift. Our fall risk and pressure ulcer assessments are there also and we will be starting med reconcialtion soon.We are just having some problems charting everything in real time and while we can adjust the time the paper trail would show we altered the time. So any suggestions for getting better at charting in real time, it is a surgical unit and we can get 2-3 pts back at the same time , each on post op VS and many on q hour RR and sats, as well as tele. We generally have 1 nurse for 4-5 patients.