Survey: Does your facility use a paper or computer based charting for patient record

Zinnia · May 15, 2003

We are going live onlline in October. The problems are many,and I am used to a computers!

I can't see the docs using them ,but using us. We were instructed in class to say..."I will show you how to look up lab results Dr.Hatesbeingadoctor"

We are paper charting at present and still have a doc that wants to know the highest temp in the past 24hrs..The chart is right in front of him.

I say if we have to learn it ,so do the doctors.

homesick honey · May 15, 2003

At our hospital we are in the process of trying to implement a new Computer system. one of my roles is o make sure we get the best and easiest system for our clinicians (we expect Doctors as well as Nurses to use he system). is anyone using systems by CERNER or LOGICA IDX in their facility. i would be interested to hear about anyones experiences with these suppliers. i feel anything that makes patient care safer and easier is a good thing.

Care Assistant · May 15, 2003

We have what we call Cardex's where we write daily about the old people at the home. But it takes so long to read it as this has to be done EVERYDAY morning and afternoon and Night for Changeover staff. Some days there are like 20 cards to read it is crazy.

angelbear · May 19, 2003

Ok I admit to being computer stupid. Our facility is paper but what I was wondering is how would you sign your nurses notes on the computer or your initials in the MAR. Just curious we are currently having a budget problem so I dont see changing to computers any time soon. Especially since we have been in a budget crunch since I started there two yrs ago.

homesick honey · May 19, 2003

hi angelbear, if they were logging on to the computer either with a password or a proximity care or swipe card this would be like their signature. that is why they should never allow use of your password with a computer system. you don't know who would use it. :rolleyes:

angelbear · May 19, 2003

I see, thanks for answering my question.

blue280 · May 19, 2003

Homesick honey, we cerner in our facility. I think it is a good product but it can't do everything. The problem we have is ourIS dept doesn't like it so we have a hard time integrating it into our nainframe. It also "goes down" for maintanence(sp) on Sun from 3-6am. Guess who has to chart assessments, activity, treatments ect on 10pts on Sun? Yep, thats my shift. Once in a while, the computers do not come back up at 6 then its a mad scramble to chart on paper so we can leave on time (overtime is a no-no) I like computer charting for the most part its the outages that drive me crazy!

homesick honey · May 20, 2003

Thanks for that, darn mom128.were you around when they went from paper to computer? i was wondering if it was well supported by the suppliers. i am worried that it will be a case of get on with it and my colleagues are going to have a hard time. any more information you can give would be great.

many thanks

panurse101 · May 23, 2003

currently using paper....keep getting told the computers are coming....i have been hearing of some problems with computerized charting. Not sure now if I am looking forward to it as much as I was previously.

devia01 · May 27, 2003

At the moment iam goin for my clinical practice in one of the resthomes and i havent seen any computer based charting for patient record all i have seen is that every patient in the resthome has a file where they have all the information about them in the file in a hard copy.

But iam pretty sure that there are quite a number of Nurses who use Computers to chart their patient record in the hospitals.

I say computers save a huge amount of time for busy nurses.

:)

ASHISHMA

Scavenger'sWife, RN · May 28, 2003

It's a mix here.

At the main hospital where I was until Feb., we still charted on paper. But labs, test results, Xrays, H&P, etc., are on computer. A paper copy of same is on the chart. We also enter VS, I&O onto computer at the end of the shift. (That info is also on the paper chart.)

In Home Health, where I am now (same hospital), we have laptop computers for OASIS, and we all fill out our time sheets on computer. Two of the RN's have "gone live", meaning they do *all* their charting for daily visits as well as everything else on computer. We will all be going "live" by the end of the year. The two RN already there are helping streamline the program, sorta "beta-testing" it before mass comsumotion.

Getting back to the hospital itself: I see several of you mention MDs being resistant to the use of computers. We had a hard time getting ours to look up results for themselves also. But finally Nursing Admin mad a rule that we WERE NOT ALLOWED to look up results for the doc. They all are able to take the same course *we* took when we were hired in that taught us how to use the programs. And they are all able to have free hook-up from the hospital to their homes to be able to look up values and results at their homes, then call in with orders if need be. We were told by Admin to tell Dr. Ihatebeingadocandihateyoutoo, "It is not my job to do *your* job." Actually, I have never had a problem.....even the most resistent MD finally "got it" and calls up his own results (while we all hear him cursing out loud - hee hee)

:chuckle

bnsoon · May 30, 2003

Use paper only at my own facility and a mix of both where I'm doing clinical. Have to say I don't like the computer system. Even the IT department says it's outdated and clunky. I have found that it doubles the amount of work b/c most charting can be found in both places.