Knowledge Based Charting? Computer documentation

[AtlantaRN, RN]

We are starting KBC, knowledge based charting. We have just started training our "superusers," who will help educate the nurses, docs, rd, rt, etc, ALL disciplines will chart using this format...

Are there any nurses out there that are currently doing the computer generated documentation? And if so, what do you see are the current needs with your system?

Thank you for your input

linda

[snowfreeze, BSN, RN]

I recently started working in a facility which is paperless. We do just about every part of the chart on the computer. I was quite overwhelmed at first but now am quite comfortable with charting on computer and the ease of looking up just about anything in the chart from any computer (one in each patient room, at least 12 at the nurses stations and 4 COWs[computer on wheels] on each unit. I don't have to 'look for a chart' anymore.

If you are going to consider getting portable computers (COWs), get twice the number you think you will need, they are wonderful for docs making rounds and charting just outside a restless patients room.

I was not present for the onset of computer charts but I am told that they had a LOT of codes during the first 6 months or so as the staff was so concentrated on getting to know the computer programs they were not as diligent with patients declines and even not hearing alarms quickly. Have a few people designated each shift (or for set periods each shift) to be NOT concentrating on computers but doing frequent rounds on patients during this time.

Good luck and I am sure you will love computer charting.