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

toronto rn · May 2, 2003

We use computer based charting for the assessment, flowsheet, patient story and labs/tests. The actual history, orders and physician documentation and nursing notes are done on paper. Half and half still, with further progress limited by budget, and security issues.

Paprikat · May 2, 2003

All paper. No computers. Probably never will.

niteshiftnurse · May 3, 2003

all paper for now, but going to computers soon

Nurse Ratched, RN · May 3, 2003

Computers at the hospital for everything but careplans and MAR's (both scheduled to go online in the next year) and paper everything at the clinic.

unikuelady, RN · May 3, 2003

We us computer for everything. The premise behind it was to save paper. What a joke. Every 24 hours a printed summary is made of all computer charting for the permanent file. It takes what seems like forever to look up something in the computer...say a newborns feeding patten (which the doctors want to know NOW and they want YOU to look it up for them). On paper charting you just open it up and the information is all there. With the computer-you have to log in, find the pt name, bring up their screen, scroll down to feedings, enter another screen and it tells you the information. If you want to know what the last 3 feedings were, then you have to go into 3 separate screens for the information. I personaly feel it's a pain in the neck. It could be the computer program that my facility is using. Give me the choice and I will take paper charting/flow sheets in an instant. PS I have been using the computer system for 4 years now and am very quick at it. Also as a side note: it takes a large amount of time out of my shift (away from patient care) to instruct new employees and registry in the use of the charting system. (we use registry almost every shift).......but thats another story about workplace dissatisfaction. I would encourage every staff member to have input and explore different systems for charting before the institution commits to a new charting system. Thanks for giving me a chance to speak my mind.

suzannasue · May 3, 2003

We use paper only for charting purposes...slow slow slow...but this particular hospital will never use computers to expedite the charting process as long as the little tyrant MD who runs the place retires...he does not "trust" computers...he does not like women (I've been told by every supervisor/management person "that's his culture, tolerate him" well...Toto you aren't at home anymore...you are in MY country now...and I do not follow you nor do I wear a veil, so get over it...) Little tyrant refuses to read nurses' notes, states they are for the nurses not for the doctors...and you know, I get so weary of repeating information that he has in his hands but is too lazy to read...lab print outs on computers...it's a wonder the Emperor allows such high tech equipment in the hospital at all...oopppss...I rambled....oh well...little old ladies get to ramble, do we not????

jemb · May 3, 2003

We were told over a year ago that we would start computer charting in 2003. Realistically that probably means 2005 or 2006.

night owl · May 3, 2003

We use the Computerized Patient Record System (CPRS) where everything is in the computer including Bar Code Medication Administration (BCMA) and have been totally paper free for about four years now. I love it and if given a choice, I would never go back, but we do waste alot of paper. The one thing I find annoying about it is finding print-outs with the patient's SS# and confidential information just lying around the nurses station. Every nurses station is equiped with a shredder which people tend to forget to use. If JACHO comes around and sees these print-outs exposed for public view, they will cite you in a heartbeat.

gwenith, BSN, RN · May 3, 2003

My previous job was completely computerized - computer at the end of every bed (ICU) but I could have written a better program myself (and THAT is saying something!!!). Honestly! It was partly the WAY in which it was utilised as well that drove me insane. Despite detailed patient assessment mandatory to be finished within 15 minutes of starting shift (no matter what else was happening) there was no nursing care plans!!!!!

Oh! there was a tick sheet for cares i.e. mouth, eye sponge etc. but what happened is that it seemed to perpetuate a culture of "Boxes must be ticked" no matter what the patient really required. A patient would get 2nd hourly eye care whether or not they needed it while other cares were neglected especially those "special interventions".

The drug list was computer generated and although it did come out a a clear "worklist" that helped to reduce missed doses it also had its clear limitations such as an inability for dual signatures to be entered.

There were many other problems with the system. I now working in a unit using paper and am much happier about the care I can not only deliver myself. ( I have the ability to make independant decision not just tick boxes) :rolleyes:

POPRN · May 3, 2003

where I work we use paper. the rest of the house is going to computer charting. I work in the OR. right now I have at least 6 pieces of paper that I have to chart on. that is not counting the charge sheet or the implant record!!!!!! have to go thru the main desk for labs, frozen sections, etc...

pwp1289 · May 3, 2003

we are almost totally "paperless" only i+o,flow sheets and tx sheets on end of bed clipboard are paper--all orders are on computer and go directly to pharmacy,lab,dietary,radiology,consults etc. we have even been doing BCMA (bar code med administration ) for 4 years now-will soon be scanning bedside sheets so all will be in computer--i love both systems!!!!!!!!