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Discussion

Implementing a new computerized charting system

Looking for some feedback from nurses in all acute care fields but also curious about pediatrics. Our institution is going to start using a new computerized charting system and there are teamsworking on building how the system will be set up. We had a different brand of charting in the past and it was charting by exception. As the teams work though this process some members of the team feel that a charting response of "WNL for developmental age" or "WNL for patient" or "patient at baseline" is not appropriate. I'll refer to these people as the "againsts". They feel that the charting should be based on the normally healthy adult. For example, a patient who is in a persistent vegatative state is admitted to the hospital for persistent fever. The patient also has a g-tube which is obviously used for all of their feeds. The g-tube and that type of feeding is the patients baseline. Other members of the team feel that if you chart this as an exception it appears as if this is not normal, therefore something that needs to be addressed while the patient is hospitalized despite the fact that this is their normal, that this is not normal for a patient who otherwise does not have any problems, but it is normal for that patient. It is their reality and more than likely will not ever change and does not need to be changed because they are tolerating that type of diet and it is meeting their nutritional requirements.

The againsts feel that every possible exception needs to be built into the computer program. Using diet as the example, this means that anyone who is on anything different that an regular adult diet, would have to have an exception charted. People for the "WNL for patient" or "Baseline" charting (i'll refer to them as the "fors"), argue that the situation listed above is that particular patient's normal and therefore should be charted as normal for patient or "patinet at their baseline". They also feel that this would add an astronomical amount of options to have to choose from and add more work to the aready over-burdened nurse. In cases in which ther is a specialized population such as Peds or NICU, or even Palliative care, almost every section of charting would end up being exceptions because normal charting is based soley on normal healthy adult.

Looking for others who have computerized charting and what they do. I'd appreciate answers from all types of nurses but feedback from specialized patient populations would be great to hear from also.

Thanks

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We have used computerized charting by exception for many years. Anything that is not "normal" for an average healthy person of that age group is charted as an exception. I think of it as the "WalMart standard." If you would be a bit surprised to see a finding in the average WalMart shopper, it is not normal. That means that foleys, IVs, diminished breath sounds, activity intolerance, etc. need to be charted on. And it really doesn't require all that many "pick list choices"; anything really unusual can always get taken care of with a note. I don't believe referring to a particular patient's baseline is appropriate in an assessment. That would come in when you are considering goals and expected outcomes.

We are currently using Meditech computerized charting in our ER, first department in the hospital to use. We are transitioning to the entire house using this program. Meditech IS a little archaic, but it does function fairly well once you get used to it. This could be said for almost any system, I believe as I have worked with a few... I found, after working with them, that having a lookup screen with the most commonly used phrases, and being able to type long hand in any response you would like, works really well. In our system, if you type a response that is not in the "lookup" screen, it asks you if you want to use the "unrecognized format", and you can choose to enter it or not. This way, if those who do not feel like they have all the options they would like available, then they can make up their own. :redpinkhe This allows everyone to be happy, and get the point they are seeking to portray across. Hope this helps!

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Thanks for your feedback. Could you tell me what types of patients you work with (i.e. adult, peds, OB, Neonates, etc.)?

I work with acute care adult medical and surgical patients, a variety of diagnoses.

I work ER. We get everything.

Currently, our facility uses Meditech. We are a stand-alone pediatric facility. We are documenting in our inpatient units but not in our ER. Our nursing staff have several assesments built that list both normal and abnormal values for systems. Essentially, it is not charting by exception since you have to "click" a value for assessment. However, none of the values explicitly state "normal" For instance, for breath sounds, you would "click" or select "clear"not normal. You must explicitly document your findings. The nurses don't have to use narrative documentation. The assessments provide them with the majority of "normal and abnormal results.

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