Paper Charting venting

Nurses General Nursing

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  1. How does your unit/facility chart?

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Hey everyone! I am not sure if I am here to vent or to ask for any words of wisdom. I just finished my orientation at my new job last week as a new grad. I got four orientation shifts in total (as I am casual). While I was running around trying to figure everything out I got good feedback that I was going to do great. BUT my biggest issue is the paper charting. Throughout school we have electronic charting so that's what I am used to. But the paper charting is adding a lot of extra stress to trying to figure everything out. And having to try and read doctor's orders is so hard and time consuming (I know....get used to it). I know a lot of places paper chart, and that used to be the way everything was done, but I feel like I don't know anything because trying to figure out where to find certain information, document certain things, is taking up so much more time than if it were electronic charting. I feel horrible for venting about it as it clearly works on the unit but I am just having trouble starting as a new grad having to learn how to document…Really dreading my first shift on my own.

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

Nah, the Liberals will never fund it. It's not a sexy, politically correct thing. Can you imagine Trudeau trying to take a selfie with a computer screen!

Specializes in ICU; Telephone Triage Nurse.
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! :)

Wow! Really? I am pretty surprised to hear there is a hospital in the US that has held out this long so far and not yet switched. A MD's private practice, sure - but a facility? That is stunning.

The very last transition to EMR from paper charts I lived through was while working at a VA MICU/SICU in ... 2002 (????). Yes, that was it, because I remember calling off for training in the computer lab for this (of course on my day off :mad:) due to 9/11/01 had occurred and I was too afraid to drive onto the grounds of a government facility.

Eventually the actual day arrived and with it the change had occurred - but patient care and surgeries went on as we all stumbled to catch up. Getting actual post-op admission paper work was beyond belief - challenging one's coping skills and problem solving abilities. Brutal.

It's almost as if you got lost in a worm hole or vortex, and got spat out in 1994!

Nah, the Liberals will never fund it. It's not a sexy, politically correct thing. Can you imagine Trudeau trying to take a selfie with a computer screen!

HAHAHA. This is gold!

Wow! Really? I am pretty surprised to hear there is a hospital in the US that has held out this long so far and not yet switched. A MD's private practice, sure - but a facility? That is stunning.

The very last transition to EMR from paper charts I lived through was while working at a VA MICU/SICU in ... 2002 (????). Yes, that was it, because I remember calling off for training in the computer lab for this (of course on my day off :mad:) due to 9/11/01 had occurred and I was too afraid to drive onto the grounds of a government facility.

Eventually the actual day arrived and with it the change had occurred - but patient care and surgeries went on as we all stumbled to catch up. Getting actual post-op admission paper work was beyond belief - challenging one's coping skills and problem solving abilities. Brutal.

It's almost as if you got lost in a worm hole or vortex, and got spat out in 1994!

I am in Canada! But yes I feel like it is not 2017 here. There are actually two areas that are electronic in the provincial health system- L&D and OR. And they will actually print off those large documents (especially the L&D ones which are usually quite lengthy) and send them off to PACU/Post-partum with the paper charts. So not efficient!

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.

No all our new grads get 12-14 shifts even if they get hired as casuals.. I suggest trying to get a casual job on a medical or surgical unit to get more experience and training.

No all our new grads get 12-14 shifts even if they get hired as casuals.. I suggest trying to get a casual job on a medical or surgical unit to get more experience and training.

Wish it was like that here. As far as I heard, new grad or not, all casuals get four orientation shifts no matter what specialty. I am just gonna stick it out.

Specializes in PCU.

Being raised in the paper charting era, I used to lament and glorify the old days of paper charting. I did an EMR conversion last year and OMG paper charting SUCKS. I will never accept a job that is doing paper charting. Just too time consuming trying to figure out what is going on. How the Hell did we ever do that? Kuddos for you if you are going to give it a go. For this old chick, paper is in my past.

hope all goes well for you

Specializes in PCU.

Yeah, it is a requirement, but I think that they just pay a fine, lots of hospitals are still on paper. I travel nurse off and on and paper for me is non negotiable. Surprised to find a large hospital in New York City was still on paper and there are 2 hospitals in Tampa Florida, still on paper. That being said, some of the smallest hospitals i have ever worked at - Zephyrhills Florida- was using cerner back in the 90's. Ya just never know.

I agree... having only 4 orientation shifts is definitely troubling, especially when dealing with new nurses.

I am so glad we no longer have to decipher written orders. There are still a few holdout physicians and surgeons that still believe in the handwritten order. Electronic orders eliminate misinterpretation of medication orders that could potentially be life threatening. With electronic charting a patient's drug allergy is in the system and this prevents medications that a patient is allergic to being ordered.

I will admit, I still chart notes on each and every patient I take care of during a shift. I have been a RN since 1994 and have never been to court however; I know some that have and they regretted not writing a note since they did not remember the patient nor the circumstances that resulted in the patient filing a medical malpractice suit.

Specializes in CWON.

4 shifts is not nearly enough...and mgt should be ashamed of themselves. ..but sadly it's not uncommon for training to be minimalized. With regards to paper charting...it can be challenging to adapt to...but, in my opinion, it also helps develop strong skills/habits in nursing. There are no prompts in assessment or patient identification or writing a decent prog note. Those skills become yours deep down and encourage critical thinking. EmRs are fabulous and definitely offer built in safeties when a good system is being used..but there are upsides to paper charting for new nurses. If you stay, despite the lack of training, just focus on really learning how to utilize the basic tools you were given in school and grow them. Just trying to provide an upside...

Hey everyone! I am not sure if I am here to vent or to ask for any words of wisdom. I just finished my orientation at my new job last week as a new grad. I got four orientation shifts in total (as I am casual). While I was running around trying to figure everything out I got good feedback that I was going to do great. BUT my biggest issue is the paper charting. Throughout school we have electronic charting so that's what I am used to. But the paper charting is adding a lot of extra stress to trying to figure everything out. And having to try and read doctor's orders is so hard and time consuming (I know....get used to it). I know a lot of places paper chart, and that used to be the way everything was done, but I feel like I don't know anything because trying to figure out where to find certain information, document certain things, is taking up so much more time than if it were electronic charting. I feel horrible for venting about it as it clearly works on the unit but I am just having trouble starting as a new grad having to learn how to document…Really dreading my first shift on my own.

Ive been a nurse for a long time, plus I used to be a travel RN, so I've worked with a lot of different charting. That being said, IMHO, if you're having a difficult time with the paper charting, the best thing to do is sit down with all of the different papers and see which one "flows" with the others. Don't panic, slow down, and just pick through it and sort it out. It's easier to understand the charting, then it is to just memorize it. Take a bit of time before or after a shift when you won't be interrupted.

Also, keep in mind that when it comes to electronic charting, it's not perfect. Computers can crash, they require maintenance and updating, etc, and then ultimately you need to rely on paper charting. LOL

It's been around successfully for a long time, and used by many. You'll catch on! :)

I agree... having only 4 orientation shifts is definitely troubling, especially when dealing with new nurses.

I am so glad we no longer have to decipher written orders. There are still a few holdout physicians and surgeons that still believe in the handwritten order. Electronic orders eliminate misinterpretation of medication orders that could potentially be life threatening. With electronic charting a patient's drug allergy is in the system and this prevents medications that a patient is allergic to being ordered.

I will admit, I still chart notes on each and every patient I take care of during a shift. I have been a RN since 1994 and have never been to court however; I know some that have and they regretted not writing a note since they did not remember the patient nor the circumstances that resulted in the patient filing a medical malpractice suit.

Luckily, my first week of alone shifts have went well. And I find that currently people chart by exception, so there aren't many progress notes by the nursing staff. When it was electronic, it was always required to write a shift summary, and give a full verbal report at each patient's bedside.

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