Home Visit Nursing - what are your charts like?

[hezasan]

Hi,

I am a home visiting nurse for pregnant gals, moms with babies, and children with special needs. We happen to be the only program in our public health clinic still using paper charting! I am hoping that we will be transitioning to electronic charting soon, but in the mean time--

Is anyone else using paper charts? How long would you say it takes to complete an initial chart setup? What about a follow up visit?

For those recently transitioned to EHR -- how did it go? What is the worst thing and best thing about EHR compared to paper?

Is your electronic charting mainly text-based, or check-box based? Charting by exception or not?

Does anyone do a "low tech" EHR, such as file folders on the computer? What kind of liability/security issues are present/foreseeable with this kind of charting?

Thanks for all your collected wisdom!

[Sunmoonstars]

Hi Hezasan-I started in PH 3 years ago in similar program. I went from acute care to PH dept. Was using EHR, and PH had *just* transitioned to EHR 6 mos prior to my arrival, so I know no different. But I am old enough (18 years as an RN) to recall paper charting at the hospital,and EHR is by no means easier. I think it takes more time. What is nice is being able to look up hx quickly, and not have bulky charts to lug around. My boss can audit my charts when I'm out in the field. Our current system is check box plus text.The mandatory areas are highlighted in red. We chart WNL vs abnormals, and abnormals of course, need text added. As an RN who used EMR in the hospital for close to 10 years, it was an easy switch. I have heard some others who were not used to EMR found the transition difficult. Good luck!