Computer charting for clinical instructors

globalRN · Oct 14, 2002

Wow...15 is a lot of students. How many patients in total? If you find it 'virtually impossible' to check their charting....Have you discussed this with other instructors(who probably have the same problem)? With the school's management?

I used to get all my students to chart their on-shift assessments. Once you have reviewed that it gave them a fair idea of what they needed to do and to be anticipating. Of course, with students...there's a lot of editing/teaching along the way to the final input. Then it was always easier to chart later on if needed and for final entries.

Because the documentation is a legal record, reviewing is mandatory cause they need to be countersigned by you or the RN

sjoe · Oct 14, 2002

Most of these kinds of software packages are set up as "management information systems," i.e. for the convenience of the managers, which includes their being able to access all the entries of those they supervise. Talk to the unit manager(s) and find out what special code you need to use to do so and exactly how to proceed. These kind of codes are NOT listed on public web sites and BBs, for obvious reasons.

VickyRN, MSN, DNP, RN · Oct 15, 2002

The way I look at it, I am a NURSING instructor, not a COMPUTER TEACHER (although, the facility would love to have it so, LOL). It took me a solid month to learn the ins and outs of computer charting at this particular facility. And now, there are endless flow sheets and forms on the computers, with more sprouting every week. So, I don't expect too much from my students computer-wise--they're only on the unit for 4 to 6 clinical days at a time. I tell them to not be intimidated, that I will not count off for their mistakes on the computer (as long as they are making a decent effort. If they screw up REALLY bad--like leaving off an entire set of vital signs--then I will down grade.) If they mess up, well, I go back in to the computer and edit their entries. Otherwise, if they meet BASIC requirements, that's good enough for me.... DON'T SWEAT THE SMALL STUFF. Maximize your time. Make the clinical time enjoyable for the students--a positive learning experience.

Nurse Ratched, RN · Oct 15, 2002

At our facility we have gone back and forth about whether or not the nurses working on the unit are supposed to co-sign with students instead of their instructor. Since I still complete an assessment, I would have no problem with co-signing with a student and reporting back to the instructor. That's also the way it was done when I was a student.

Edited to clarify that we have a "co-sign" screen in our clinical documentation in case it's needed.

sjoe · Oct 15, 2002

"The way I look at it, I am a NURSING instructor, not a COMPUTER TEACHER "

A computer is just one of the necessary tools that nurses have to learn, like IV pumps and thermometers. It is only reasonable that a nursing instructor either directly teach students use of these and other machines necessary in a particular clinical setting, or arrange that someone else teach them to do so in a timely way.

At the school I attended, before taking his/her first clinical course, every nursing student had to complete a basic computer orientation taught in small groups by one of the instructors after regular classroom hours. Then, as a regular part of clinical orientation, each instructor showed us how to use the computer system in operation at that particular clinical placement, just as he or she showed us how to use the phone system, where the cafeteria was, etc. Made sense to me. Perhaps your school could do something similar.

RNConnieF · Oct 15, 2002

I always co-sign with a student. I also chart "0800-Reviewed student nurses assessments and charting." I always go over the assessment and charging with the student so that if there are additions or changes the student makes them in his/her own handwriting and then I can just co-sign.

P_RN, ADN, RN · Oct 15, 2002

We use McKesson HBO Care Manager. The students entered their vital signs and treatments they did. The then documented with a narrative other notes applicable. The instructor reviewed these and cosigned. The assigned nurse for that patient had to complete the chart and initial what she did. I always included my name---RN working with her name___SPN. Then when she left I documented that too. Most of the time they were excellent, and sometimes they wereway ahead of the rest of the class.

The program tool is probabl;y different now, but I have never cosigned a chart with any one unless we were splitting a shift.

globalRN · Oct 15, 2002

The important thing is that all the students' care and documentation is reviewed and signed off by a RN

(instructor or the RN caring for the patient).

Students love it when the RNs take the time to help them hone charting skills...kudos to you RNConnieF. And we know how hairy some of your days have been. All power to you!