Computer charting..Uhggg! - page 2
does anyone else out there tire of using computers all the time for charting and wish that the chart reflected the continuity of care it used to with time for time documentation that you could follow... Read More
Jan 1, '07Occupation: RN Specialty: * Cardiology * Oncology * Medsurge RN ; Joined: Dec '06; Posts: 1,220; Likes: 855Just spoke to a fellow coworker and she stated two reasons why she doesn't like computer charting: information has been lost in the past during malpractice suits...meaning no paper trail and someone can easily go into your chart using another person's ID and modify your charting...Computers are perfect right...well, have you seen the movie "2001." ???Last edit by CaLLaCoDe on Jan 1, '07
Jan 1, '07Occupation: Nurse Specialty: Neuro, Critical Care ; Joined: Apr '05; Posts: 1,562; Likes: 112I love computer charting. It cuts my charting time in half. It's easier to read and within seconds (for me) I can view all my vitals since adm, read all the labs, etc. I have paper charted before and I hated it. It was hard to read, messy and time consuming, for me. I can type a progress note in a fraction of the time it would take me to hand write it. The one thing we lack is comptuerized order entry...I dread having to decifer other's handwriting and sometimes it takes forever to figure out what the order actually says.
Jan 1, '07Specialty: Med-Surg, Wound Care ; Joined: Apr '03; Posts: 740; Likes: 296Quote from TeleRNerWith our computer system the original charter is the ONLY one who can make modifications. If that restriction is not on her system, that is a BIG problem that should be addressed.meaning no paper trail and someone can easily go into your chart using another person's ID and modify your charting
I love computer charting!! (and I'm old!!) But I have to agree that most facilities still love to add on redundant paper trails, usually due to doc's objections. Example: vital signs in the computer and doc's still want them on the old graphic chart.
Jan 1, '07Joined: Jun '06; Posts: 314; Likes: 46I love it! If it is a well-designed system, and you take the time to learn how to use it, it can make your charting much easier. The ones I've used have an extensive list of descriptors that you can choose either from a drop-down box or a check box. This is especially handy when you can't quite find the right words to describe your assessment findings. You can easily scroll back to review notes previously entered by other nurses, and you have the option to indicate 'no change from last assessment' or to add any new stuff. Then you save it and you're done. When you're documenting an assessment a cartoon body pops up and asks you to point your mouse to the areas on the patient's body where there are problems or potential problems. Click on the body part and the system asks you to type in a keyword for the problem your are documenting on. After you type in the word it brings up a list of problems and potential problems and asks you to choose, then it fills in the language for you. Next you are prompted to indicate your interventions. You can either choose your interventions from a list, edit the ready-made options in the list, or type in your own words if you want to. If you select the 'notify MD' option you are prompted to type in the first few letters of the MD's name and a box with a list of MD names and their contact info pops up, choose the one you want and whatever time you indicated that you notified the doctor is saved into the notes. Then one click an 'bam' you're done. Definitely a lot easier to make a few clicks and be over with it instead of having to writing out everything on many sheets of paper for each patient. If you make mistakes or want to go back and add stuff thats just another few clicks.
Jan 1, '07Joined: Dec '02; Posts: 41,761; Likes: 48,081So far we only have computer charting for our meds and the program is called Pharmtrak and it is awful.
We have one computer at the nurse's station and two nurses and one ward clerk have access to it. So, when I need to chart I can't always chart. If I have a busy day it is easy to have to stay overtime to chart all my meds and I do not like to do that after the fact.
I think some folks would be slow at charting regardless of whether it was paper or computer . . . . I try very hard to get all my assessments written within an hour of the assessments and I make sure I go back to the charts to do updates as well. Other nurses wait until the end of the shift to start charting - that would be the same I think whether it was computer or paper. They just choose to wait.
I miss the days of having a paper med chart - we had 5 days of meds on one page and if the doc asked "how much morphine has this patient had in the last 24 hours?" all you had to do was flip to your meds and look at the piece of paper. Now, I have to have access to the computer, log in, get to the part of the program that lets me see meds (which takes about 45 seconds) and then print which literally takes about 3 minutes . . I've run to the bathroom and come back and still have had no paper come out of the printer.
I like the easy access of a piece of paper in front of me. I like a paper trail.
I love computers - don't get me wrong. I just don't like charting meds on one.
Jan 1, '07Occupation: RN Specialty: 34 year(s) of experience in L & D; Postpartum ; From: US ; Joined: Nov '99; Posts: 9,721; Likes: 11,860Stevielynn:
You said it exactly for me, too. I like just flipping up the chart and finding what I need. Logging in, having very slow computer and not enough of them is a huge problem at our place too. Places should have the proper infrastructure in place BEFORE doing anything like this. Our program is very cumbersome and I foresee lots of charting errors with this as well.