Electronic Charting Responsibilities

[bethann27]

Checking to see if what I am required to do at my job is commonplace. If you use electronic charting in a LTC environment . . . what exactly are you expected to do?

Here is a list of things that I am required to do:

1) input drs orders

2) use electronic MAR

3) update care plans after falls, skin tears etc.

4) maintain daily care tasks for CNA's (when bath days change, etc.)

5) open infection control entry when ABT is started including s/s, labs, diagnosis, interventions etc.

6) close out infection entry when ABT is finished

7) complete daily skilled assessments and then put note in electronic nurses notes

This list doesn't include the other paper responsibilities such as body audits, monthly summaries, weekly census, ordering supplies and stock meds . . .and I'm sure something else that I'm supposed to do that I have forgotten. On a side note, we do not have a treatment nurse - I do those too.

I love my job, but it seems to be a bit much at times . . . . is this the norm or have I taken on an unreasonable position? Any thoughts, comments, encouragement or experiences are welcomed.

[misschiatia]

Do you have a CMT? What about your pt staff ratio? Is it one nurse with no cmt and 3cnas for 50 pts(10 of them medically complex/fresh from the hospital) or is it 1 nurse with a CMT to pass her pills and 3 CNAs to help her with 30 residents?

[misschiatia]

Nurses at the LTC where i work are required to input dr orders, use electronic MAR and document skilled assessments as well as charting by exception, keeping up with and arranging transportation with the campus van, skin assessments biweekly, and miscellaneous other small(accuchecks, supervise staff, etc). I love the EMR(electronic medical record.) But you have to be able to type

[bethann27]

It is 20 pts in two green houses - 10 in each house; 1 nurse for both houses, 2 CNAs to each house - they cook, do patient care, laundry etc. We do not have a clinical director. I do the med pass.

[CathyLew]

I think you are going to see a lot of big changes with the electronic Med record in the next few years. Right now everyone is scrambling to meet meaningful use of the EMR. It may get harder, just at the point where everyone isn't comforatable with it,,.... then it will level out. What is really neccisary.

We are just looking at the LTC Electronic record. So I don't know if that is excess or not. Interested in hearing what others say.

But, I do have to add....the times they are a changing. you will see more and more computer charting required.

[misschiatia]

Your staffing ratio is sounding pretty good from the outside looking in. Your CNA's have only 5 residents each. Thats pretty good in LTC. But with no CMT, you are probably pretty busy. Does the management team(DON/ADON/MDS NURSE) also participate in upating careplans/ overseeing and helping update daily care tasks/keeping up with infection entries?

[bethann27]

Yes, all of the above do participate. However, I'm reminded that it is my job when I ask for help.

Just wondering if everyone else out there is doing the same stuff. If so, then I'll keep working on my speed and trying to remember what has to be done. If not, it might be advantageous to look for another position.

[GymNurse]

Nursing is not nursing anymore.. its' all electronic patient care. We spend all of our time trying to figure out where to acurately chart in a computer rather than acurately taking care of the patients. We are being given more patients, more responsiblities, with less ancillary support from administrative. We are told we have to do this way so it makes things look good on paper to the powers that be. And people wonder why there is a shortage of nurses.

[sissie43]

We have the electronic charting in our faculity and we love it. The management nurses help with orders. I am the MDS Coordinator and help with orders and care plan updates and summaries