Electronic records and computerization:Improving care or creating more chaos?

Nurses General Nursing

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As our hospital moves towards more and more computer driven care, I'm finding it more difficult and frustrating to be a nurse. I'm really getting tired of this new aspect of life. I was talking to my social worker friend and she is also suffering under this. She works for mental health.

I just seems as if, as well meaning as it might be, it's not accomplishing it's goal. It's creating more chaos at the the bedside and more job security for tech support and computer companies. They keep tinkering with the systems and cause unexpected problems. Recently I went to put in some orders and there was a glitch in my unit's computers. I had to take my orders to another unit and have the unit secretary there enter my orders, even though I had the time to do it and she was busy with something else.

I'm wondering if we are setting ourselves up for a huge infrastructure collapse. I also question the wisdom of putting our faith in computer programmers. It seems as if their programs always fall short and cause the bedside nurse frustration and grief.

Specializes in L & D; Postpartum.

I personally hate it. I know for a fact that my charting is far from complete now that we have the program we are using. I find it difficult to find anything on the "pages" and just trying to figure out what the nurse before did or didn't do is like looking for a needle in a haystack. Trying to cover all the bases is far more difficult now with so many little buttons to push for the various chart parts. I know I miss things on a regular basis. Or at least I fear I do. So I would agree that it's a liability nightmare.

Our orders are on a separate program, so that is another problem. I'll be so glad to retire in about 2 years.

Specializes in Med/Surg, LTC/Geriatric.

My only experience with charts comes from working as a medical office assistant. I worked in a few offices with paper charts and a few with computerized charts. I FAR, FAR, FAR prefer computerized charts!!!

I worked for a very busy plastic surgeon who worked 1/2 time in the office and 1/2 time at the hospital. He could look up anything on a patient right from the computer. I did not have to pull charts for him to take to the hospital. I didn't have to fax him reports, labs etc on patients. Filing reports was easy as pie and soooooooooo much faster than maual filing. One of the other plastic surgeons in the office was still on paper charts. His secretary made at least 4-6 trips to the hosptial per week to drop charts off, pick them up, etc for her boss. She was also forever getting phone calls from him to fax a report of lab NOW. She would spend at least 2-3 hours per week filing, while my same amount of computerized filing took less than an hour.

I used to do a lot of QA on charts during down times on noc shift. What a nightmare. Poor penmanship, different writing styles, absence of essential charting criteria, etc. made paper charting a challenge on the best days and downright impossible on the worst.

Trying to make sense of chicken scratching was only the start. Once deciphered, the narratives often went downhill from there.

Where one person would leave a chatty account complete with all sorts of subjective and irrelevant details, another would be terse and stingy, using abbreviations no reputable dictionary every heard of.

Now, I can look at a patient's electronic chart and within minutes, have a pretty good idea of the last 48 hours or more.

The best set-up will have an orderly system-by-system flow sheet with plenty of check-off boxes that cover the expected possibilities. It will also have the option of adding a narrative or including unexpected values or developments.

The prime combination is a good software program, dependable and knowledgeable IT people, decent training, and management that is open to finding solutions to things that aren't working as well as they should.

I much prefer computer charting over paper charting any day. Or night.

Specializes in Trauma,ER,CCU/OHU/Nsg Ed/Nsg Research.

Our charting system sucks. It's tedious and redundant, and on some days I feel like I'm nursing the computer more than the patient. It doesn't help that we do Q1hr charting on this system, either.

Specializes in Med-Surg, Trauma, Ortho, Neuro, Cardiac.

Neither. I don't necessarily think it improves care. But I also certainly don't think it creates "chaos".

I like computer charting because it covers the entire system in a click without us having to write "lungs clear, respirations even and unlabored".

Computerized medical records are the wave of the future. As a student I have much preferred working with the computer based records over the paper based records.

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