Tell us about your computer system

Nurses General Nursing

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If you have Computer Charting at your job, please start a new topic in this category. Tell us if you like it, or hate it.

Enjoy!

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Brian Short

WORLDWIDE NURSE: The Internet's Nursing Directory http://wwnurse.com /

[This message has been edited by bshort (edited March 04, 2000).]

Originally posted by bshort:

If you have Computer Charting at your job, please start a new topic in this category. Tell us if you like it, or hate it.

Enjoy!

Our facility recently went to computerized charting and there are LOTS of problems. The biggest problem is admissions----it takes at least 45-50 minutes because there are so many screens to go through. Many of the screens don't apply to our med-surg patients, it's very frustrating. The other is the amount of paper waste, it's shameful. At the rate the hospital is going through paper, my grandchildren may not know what a tree is when they grow up!!!!

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Susie

cool.gif Our 30 bed, high-risk L&D unit went to computerized fetal monitoring over 10 years ago........then, we added "event documentation on the computer strip" (like, meds given, VE, repositioning, etc........then we added our nurses' bedside notes (like the q30" documentation during an induction of FHR, patterns, uterine activity, etc.)

.......... then, we finished up adding all our other charting onto the computers, like meds, PACU records, I&O shift totals, etc. All these additions were done over the course of the following 5 years. Everyone who thought they would hate it (us 'old' nurses who weren't "computer-literate") would NEVER want to do without again!

The system (Corometrics/Marquette/ QMI) is designed by OUR nurses for OUR unit to meet OUR needs...and that is why it works!!! It is not designed by 'geeks' who don't work at the bedside! Also, we have a full PC system at EACH bedside!!!

The idea of computerized nursing documentation MUST include PCs at each bedside... because of that very basic NURSING 101 class: you chart it when you do it/see it, etc......NOT back-charting at the nursing station when you have computer time! Try it....you'll like it!!!

Personally, I'm 49...& a nurse for >26 years....& I plan to practice at least until we have small microphones clipped to our uniforms, where I push a button, dictate a note specific for that patient & the voice-recognition program on the nurses' station computer types out my shift notes for me to review & sign at the end of the shift!!!

see ya then! Haze cool.gif

I came from paper charting then to computer charting and now back to reams of paper charting. We used the carevue system with vital signs and u.o. being defaulted over to the bedside computer. The drips were calculated, the assessments complete and the charting overall very comprehensive. Plus you could compare labs and trend vital signs. Cannot be beat for thorough charting in this age of very complicated and technological patient care.

I work at the same hospital that I did my clinicals in for school, and we have had computer charting since I have been there. I love it. There are definitely more pros than cons. I know this because we have had to do paper charting a couple of times due to technological problems. The differences I found was that with the paper charting, there doesn't seem to be enough room to document some things. Another problem I find with it, is that some nurses' handwriting is difficult to read. I love the computer charting because each body system has a page of its own to document on. I don't have to type a lot because there are places to probe specific things. Another reason I like the computer charting is because it helps to be sure all medications have been charted. I just have to go to the medications page for each pt and probe the time I gave the medications. At the end of the shift, I do an end of shift check, and it shows any medications that have not been charted. There are many other reasons the computer charting is better than paper charting, but I don't want to go on and on.

Originally posted by bshort:

If you have Computer Charting at your job, please start a new topic in this category. Tell us if you like it, or hate it.

Enjoy!

i am an rn in a small community hospital (apprx60 deliveries/month). we started using the watchchild fetal monitoring and charting sysytem about 2 years ago. it's nice in the way that i am able tochart as events are happening, but it is still necessary to do a ton of pen/paper charting (ie, meds, labor flow chart, admission record Etc). most of the charting done on the computer must also be documented in pen elsewhere, at least that's our hospital policy. so essentially we're double and sometimes triple charting, so to me, what's the use of the computers????

We are in the process of going to Invision charting for our pediatric and womens health patients. Any help in writing screens would be appreciated.

Specializes in Informatics, Education, and Oncology.

Feel free to contact me if I can be a resource. Will the application be used in a clinic or an acute care setting?

http://informatics.nurses.nu

First, the LPN scope of practice is to reassess. Once the initial assessment is done by the RN, any shift assessment is a reassessment and, as such, is acceptable for LPN to do and to enter into the meditech system. Just have the delineation made in the policy that it is a reassessment. It is now unacceptable practice for RN to co sign for such things..We are just starting our Meditech computerized charting and find it some duplicity right now but it will get better with all the new updates being provided and the interfaces between monitors now available. It will save time and prompt more focused plans for care and benefit the pt., satisfy regulations and physicians and educate some in advanced critical thinking.

Originally posted by MED/SURG NURSE:

We also have had Meditech for 2 1/2 yrs. Many good features, and we are still learning ways to customize our programs. One area we are trying to figure out now, is how can LPN's document assessments and notes within their scope of practice? Before with paper charting, the RN's would co-sign LPN's documentation, but that is not possible with our Meditech system. If anyone out there uses LPN's in the acute

hospital setting, how or do you have them document on Meditech within the "Rules"?

I am a Clinical Nurse working in Nursing Informatics. The hospital is a psych hospital only. The system used currently is Excelcare and soon will become E-Care. I am desperately attempting to round up information on these systems re: psych and any problems or successes found. I am also wanting to know if there are any psych hospitals using other electronic systems anywhere in the world? This information will be very handy as I'm wanting to apply for a scholarship that allows me to travel to another hospital(s) and compare information thjat may assist in improving health care here in Australia. Can anyone help? My email is in my personal details.

I work in a 110 bed hospital. We do have computers, but as for electronic charting it's a joke. We can pull up all the other departments to order labs, x-rays, and meals. But we still have to hand write all the patient notes, medications, assesments, etc. Orders are still handwritten and transcribed by the wardclerk/nurse. We still give oral full reports to the oncoming shift. The main office keeps telling us SOMEDAY we will upgrade. But after seeing all of the layoffs, and cutbacks I really don't think we will ever see any type of upgrade to our hospital. I feel like we will be lucky if Houston doesn't try to close us down in order to keep Beaumont open.

Any coments?

Originally posted by SLee:

Does anyone work at an institution that has computerized nursing documentation that is intuitive? ex: When you do the assessment, the system will formulate a preliminary care plan for you and then allow you to add, edit, or delete as necessary? Also, as further assessments are done, it will update the care plan based on the most recent assessment.?

My LTCF/Rehab (121 beds) uses a system like you describe, only the care plan is not automatically updated. However, a new preliminary care plan is generated from each MDS. The system is Management Data, Inc., or MDI. I also replied to a posting under "Long term care plans" regarding the system. I am Care Plan Coordinator at my facility and really like the system so far. We have been using it since July 1999.

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