Paper Charting venting

dayandnight · Jul 24, 2017

I studied in the states where most things were charted electronically. Moved to Canada and had to pick up paper charting (BC) which I at first hated so much due to the amount of redundancy that would occur from charting on flowsheets (ticky sheet) as well as writing out words on paper. Don't worry. It takes a while getting used to. New grad RNs in BC get 12 shifts. in the medical surgical setting... The East I guess expects a lot from their new grads

AlwaysLearning247, BSN · Jul 24, 2017

In my opinion, I'd be more scared of only having 4 days of orientation! You'll get used to paper charting, it takes time. My first two nursing jobs were paper charting. I think you deserve a longer orientation though! I've been a nurse for 2 years, I worked on a med/surg tele floor for a little over a year and just got hired at a new hospital and the orientation is 12 weeks, shorter or longer depending on what I need. Good luck! Everything will come to you in time. If you feel like you need a longer orientation please do not hesitate to speak up!!

3ringnursing, BSN · Jul 24, 2017

I remember in nursing school (spring 1991 - fall 1993) they told us we needed to take a computer course because that was the way charting for the future was headed :borg: (LOL). Of course, the computer class was DOS format and like another language - practically useless, only making me more anxious ...

My NCLEX study guide book had a CD in the back I never once opened (I, like 90% of the population didn't own a home computer in 1993).

I also took the last pencil and paper NCLEX: everyone in AZ ready to take the February 1994 NCLEX drove to Phoenix to sit for the exam - (4) tests, 100 questions each, spread over 2 days ... I did it 8 1/2 months pregnant.

... But I digress ...

Most facilities when I began work as a new grad RN in 1994 proudly boasted some type of rudimentary computer charting - most were hand held mobile units that were similar to present day versions of tablets (only thicker, wider and a lot heavier) that loaded into docking stations around the unit to charge (I think our unit had 5 of them). They were mainly used for the PCT's to take vital signs, documentation of FSBS's, and I&O's (the exception was ICU, where everything was meticulously written by hand - which also included Swan-Gantz and/or balloon pump data). Patient assessments were also here too, however we still had to write a narrative note in the chart for every patient each shift.

All orders were written in a real (i.e., physical) hard copy patient chart.

{* DISCLAIMER: I haven't worked direct bedside patient care since 2002, so I don't know if these even still exist any more. In the event they don't, and you have no idea how a physical -vs- a virtual/EMR patient chart sizes up to one another, I shall be delighted to describe this amazing, archaic archeological artifact to you!} :oldman:

A patient chart [circa 1994] was a heavy weight binder (and depending on the facility, opened either liked a book: side-to-side, or flipped open: top to bottom).

Actual orders were written (and I use the term "written" loosely, depending on the doctor's penmanship legibility - thus the ability to read said orders was at times a challenge, as some appeared to have been written in ancient Sanskrit instead of English, or using a Fx'd foot instead of a hand - but again, I digress ...).

Orders were written in black ink only, on triplicate tricolored paper (white, yellow, and pink - white stayed in the chart, yellow went to pharmacy, and pink - I cannot recall where it went). Pages were perforated length wise across the page (3 or 4 per page) or easy tearing. The first unit I worked on sent orders to the pharmacy by a pneumatic tube system - similar to a bank drive thru.

The chart was always in high demand, and NEVER where is was supposed to be - usually growing legs and wandering away, especially when needed badly. Likewise, doctors tended to leave charts in inconvenient, if not hidden places (I often wondered if some interns and residents opened a vortex into another dimension, simply dropping them into a completely different universe - never to be seen again). :bored:

Tracking down individual charts was a nightmare, as they floated everywhere but where they should have been: in a wire rack in the nurse's station.

Medication sheets were also hand written, and divided up into routine -vs- PRN medication sheets, and kept in another binder somewhere else. If a Rx med was D/C'd it was highlighted, and the new order was written down below.

There was also something called a Kardex - a large square index card that was the patient orders snapshot at a glance. This told you dietary orders, allergies, IVF's and gtt rates, activity orders, VS frequency, et al. This too had a tendency to vanish (although where I'm not sure, because doctors weren't interested in them). These were kept in a plastic container with a snap top lid (like a roladex) and especially handy if you taped report for oncoming shifts.

Like I said, I don't know what of this archaic system remains in use on the average unit to this day (hopefully none of it, as most was a PIA) however, eventually the time came when the change from paper to computer charting occurred, blessing every facility with unlimited mayhem and chaos (and also bad tempers, gnashing teeth - and maybe some tears too). I was fortunate enough to live through it several times in fact, at as many different facilities during my nursing career.

Even though paper charting was inconvenient and dated - it was what we used and what we knew. The change over was never painless or easy, and it was also time consuming. It was preceded by multiple training classes, and reams of written material often causing increased anxiety and innumerable complaints. :facepalm: :banghead:

When the EMR fairy paid your facility a visit it was always painful. Change and growth is often painful - even when it really is for the overall good (and even when we all knew it). :blackeye:

So, when you say you are vexed or stressed about paper charting - something that must seem like an 1890's wax tablet Dictaphone to a child of the computer age? I get it. It's outside of your comfort zone, and that causes stress (or distress, whichever way you want to look at it). You have every right to feel as you do.

But ultimately the EMR/EHR fairy pays a visit to everyone eventually. Heck, if you stay there long enough you may even get to experience it - just when you settle in and become comfortable with the written charting (unfortunately, I've found in my own personal experience that's when it usually happens).

My last PCP (bless his heart) was in practice for over 40 years when he suddenly died in his early 80's (he was still practicing full-time, and he was THE greatest MD I have ever known). He still used paper charts right up until the very end (I volunteered at his office while I was on medical disability to accumulate the necessary hours I needed to keep my RN license active by doing his Medicare gaps lists. At times finding a patient chart was neigh to impossible - there was even 1 or 2 that never could ever be found). Doc H's biggest fear was that he would be forced to convert over from paper to EMR's or risk losing certain hospital practice privileges, and other sanctions. I thank God he never had to face that (and we didn't either - it was a huge practice).

This long winded tale in the wayback machine boils down to this: Your comfort zone is really only relative to what you are used to. But you will catch on amazingly fast once you get used to it.

I wish you much luck and immense happiness in your new nursing job!

raindrops1234 · Jul 24, 2017

Haha....now you know a little about how it felt to switch to computer charting - and I'm by no means computer illiterate! :)
There are plenty of reasons I'd never want to go back to paper - but every once in awhile I feel pretty nostalgic about it. It was just so simple: Do assessment, write it down. It was just "slightly" more straightforward than...search lists of non-applicable things, click. Search another list, click. Search, click. Click, click, click......
Although...those of us with those 4-color clicker pens were clicking away long before computer charting. LOL...

Haha yes I know, I feel like learning how to do computer charting is a much steeper learning curve.

And I actually went and bought a 4-color pen on my second shift! And a bunch of highlighters....trying to look as organized as possible (haha)

raindrops1234 · Jul 24, 2017

I studied in the states where most things were charted electronically. Moved to Canada and had to pick up paper charting (BC) which I at first hated so much due to the amount of redundancy that would occur from charting on flowsheets (ticky sheet) as well as writing out words on paper. Don't worry. It takes a while getting used to. New grad RNs in BC get 12 shifts. in the medical surgical setting... The East I guess expects a lot from their new grads

Yeah, I think it is just because I am casual (per diem). I know others who have gotten lines and get 10-14 orientation shifts depending on their line.

raindrops1234 · Jul 24, 2017

In my opinion, I'd be more scared of only having 4 days of orientation! You'll get used to paper charting, it takes time. My first two nursing jobs were paper charting. I think you deserve a longer orientation though! I've been a nurse for 2 years, I worked on a med/surg tele floor for a little over a year and just got hired at a new hospital and the orientation is 12 weeks, shorter or longer depending on what I need. Good luck! Everything will come to you in time. If you feel like you need a longer orientation please do not hesitate to speak up!!

Thanks for the reply! I guess I should have mentioned I got four days of classroom orientation (but only two of those were nursing specific tasks). Still completely different from orientating on the unit though!

Green Tea, RN · Jul 24, 2017

I definitely cannot work at a facility where paper chart is required. Especially I don't know what to do with order or note written in cursive... I hear you.

raindrops1234 · Jul 24, 2017

I remember in nursing school (spring 1991 - fall 1993) they told us we needed to take a computer course because that was the way charting for the future was headed (LOL). Of course, the computer class was DOS format and like another language - practically useless, only making me more anxious ...
My NCLEX study guide book had a CD in the back I never once opened (I, like 90% of the population didn't own a home computer in 1993).
I also took the last pencil and paper NCLEX: everyone in AZ ready to take the February 1994 NCLEX drove to Phoenix to sit for the exam - (4) tests, 100 questions each, spread over 2 days ... I did it 8 1/2 months pregnant.
... But I digress ...
Most facilities when I began work as a new grad RN in 1994 proudly boasted some type of rudimentary computer charting - most were hand held mobile units that were similar to present day versions of tablets (only thicker, wider and a lot heavier) that loaded into docking stations around the unit to charge (I think our unit had 5 of them). They were mainly used for the PCT's to take vital signs, documentation of FSBS's, and I&O's (the exception was ICU, where everything was meticulously written by hand - which also included Swan-Gantz and/or balloon pump data). Patient assessments were also here too, however we still had to write a narrative note in the chart for every patient each shift.
All orders were written in a real (i.e., physical) hard copy patient chart.
{* DISCLAIMER: I haven't worked direct bedside patient care since 2002, so I don't know if these even still exist any more. In the event they don't, and you have no idea how a physical -vs- a virtual/EMR patient chart sizes up to one another, I shall be delighted to describe this amazing, archaic archeological artifact to you!}
A patient chart [circa 1994] was a heavy weight binder (and depending on the facility, opened either liked a book: side-to-side, or flipped open: top to bottom).
Actual orders were written (and I use the term "written" loosely, depending on the doctor's penmanship legibility - thus the ability to read said orders was at times a challenge, as some appeared to have been written in ancient Sanskrit instead of English, or using a Fx'd foot instead of a hand - but again, I digress ...).
Orders were written in black ink only, on triplicate tricolored paper (white, yellow, and pink - white stayed in the chart, yellow went to pharmacy, and pink - I cannot recall where it went). Pages were perforated length wise across the page (3 or 4 per page) or easy tearing. The first unit I worked on sent orders to the pharmacy by a pneumatic tube system - similar to a bank drive thru.
The chart was always in high demand, and NEVER where is was supposed to be - usually growing legs and wandering away, especially when needed badly. Likewise, doctors tended to leave charts in inconvenient, if not hidden places (I often wondered if some interns and residents opened a vortex into another dimension, simply dropping them into a completely different universe - never to be seen again).
Tracking down individual charts was a nightmare, as they floated everywhere but where they should have been: in a wire rack in the nurse's station.
Medication sheets were also hand written, and divided up into routine -vs- PRN medication sheets, and kept in another binder somewhere else. If a Rx med was D/C'd it was highlighted, and the new order was written down below.
There was also something called a Kardex - a large square index card that was the patient orders snapshot at a glance. This told you dietary orders, allergies, IVF's and gtt rates, activity orders, VS frequency, et al. This too had a tendency to vanish (although where I'm not sure, because doctors weren't interested in them). These were kept in a plastic container with a snap top lid (like a roladex) and especially handy if you taped report for oncoming shifts.
Like I said, I don't know what of this archaic system remains in use on the average unit to this day (hopefully none of it, as most was a PIA) however, eventually the time came when the change from paper to computer charting occurred, blessing every facility with unlimited mayhem and chaos (and also bad tempers, gnashing teeth - and maybe some tears too). I was fortunate enough to live through it several times in fact, at as many different facilities during my nursing career.
Even though paper charting was inconvenient and dated - it was what we used and what we knew. The change over was never painless or easy, and it was also time consuming. It was preceded by multiple training classes, and reams of written material often causing increased anxiety and innumerable complaints.
When the EMR fairy paid your facility a visit it was always painful. Change and growth is often painful - even when it really is for the overall good (and even when we all knew it).
So, when you say you are vexed or stressed about paper charting - something that must seem like an 1890's wax tablet Dictaphone to a child of the computer age? I get it. It's outside of your comfort zone, and that causes stress (or distress, whichever way you want to look at it). You have every right to feel as you do.
But ultimately the EMR/EHR fairy pays a visit to everyone eventually. Heck, if you stay there long enough you may even get to experience it - just when you settle in and become comfortable with the written charting (unfortunately, I've found in my own personal experience that's when it usually happens).
My last PCP (bless his heart) was in practice for over 40 years when he suddenly died in his early 80's (he was still practicing full-time, and he was THE greatest MD I have ever known). He still used paper charts right up until the very end (I volunteered at his office while I was on medical disability to accumulate the necessary hours I needed to keep my RN license active by doing his Medicare gaps lists. At times finding a patient chart was neigh to impossible - there was even 1 or 2 that never could ever be found). Doc H's biggest fear was that he would be forced to convert over from paper to EMR's or risk losing certain hospital practice privileges, and other sanctions. I thank God he never had to face that (and we didn't either - it was a huge practice).
This long winded tale in the wayback machine boils down to this: Your comfort zone is really only relative to what you are used to. But you will catch on amazingly fast once you get used to it.
I wish you much luck and immense happiness in your new nursing job!

Thank you so much for your amazing reply!!!

Everything you described about the charts, the three colored order sheets, the Kardex, separate scheduled and PRN medication administration records....we all use those! Makes me think that change will be happening within the next couple of years! Although, I am sure it will be once I get comfortable with paper charting as you said (and then will have to deal with all the kinks of a new EMR system haha).

But thank you for the advice, I have definitely taken it to heart! :)

Larry2016 · Jul 24, 2017

UM - thought it was a federal requirement now to have all electronic charting...?

milmom35 · Jul 24, 2017

That's tough! Can't believe so many places still do paper charting. It's a patient safety issue--for example, it's easy to misinterpret a medication dose. A lot of healthcare agencies would stick with outdated equipment and processes to save $$ unless a change is mandated by the government.

raindrops1234 · Jul 25, 2017

UM - thought it was a federal requirement now to have all electronic charting...?

Is it in Canada? I would love for it to be.

raindrops1234 · Jul 25, 2017

That's tough! Can't believe so many places still do paper charting. It's a patient safety issue--for example, it's easy to misinterpret a medication dose. A lot of healthcare agencies would stick with outdated equipment and processes to save $$ unless a change is mandated by the government.

I agree! Some doctor's write their medication orders quite differently. Example: MedicationA 60 mg x ii tabs (which is actually 120 mg). And yes, it may make sense to some but why don't they just say MedicationA 120 mg? Then the pyxis only has that drug in 30 mg tabs so you actually have to take out four tabs, not two, which just increases the risk of a medication error. Might seem simple, but it just seems unnecessary to me (this may also be because I am a new nurse ).

Paper Charting venting

How does your unit/facility chart?