How do you document care?

  1. I am looking to suggest to my nurse manager a better documentation flowsheet than what we are currently using. Currently all we have is a graphic area to chart VS, I/O and then areas to write narrative nurses notes. I would like to suggest a more detailed flowsheet that covers all body systems and would assure that all systems are being assessed every two hours.

    What type of system is used in your unit? Do you use computerized charting?

    Does anyone have any examples of flowsheets that they could share with me? PM me. Thanks!
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    About RNforLongTime, BSN

    Joined: Mar '01; Posts: 2,730; Likes: 604

    6 Comments

  3. by   SorenDrake
    Our unit uses computer charting, and they have for quite a while. When I first started there, it was an ancient system--they don't even make repair parts for it anymore! So about 8 months ago we switched to a newer system, an expanded version of the system we used for orders (xrays, labs, etc). There was a lot of resistance at first, especially from the older nurses who aren't computer savvy. I personally love it! You can get very detailed but it's so quick! I don't know the complete name for it, we call it C2K. It has different sections, mainly v/s, treatments, assess, restraints, and education. It has a basic amount of stuff that's loaded, and you can add in a ton of things, from skin assessments to detailed neuro assessments. Once the component is selected, it then gives you options to select at whatever time is selected. (ie it pulls up a list. for example component lung sounds left, options:clear, course, rales, course rales, rhonchi, crackles...) I'm on the committee for bringing a computerized system housewide (only CCU and extended care currently use it), and I've seen some of the newest options out there. They're amazing!
    The biggest obstacle to computerized charting is people. Some of our doctors have flat out refused to use it, and demand that we daily print all labs/vital signs trends/i&o out and put on chart, even when the nurse stands there and pulls everything up on command. As mentioned before, lack of knowledge about computers can hinder change. For most of these systems "hunt and peck" typers might have a problem. It's amazing how many people really can't do simple things with computers, and the learning curve can be really slow.
    I love computer charting. It takes me 5 minutes to document a complete and detailed assessment, I spend a lot less on pens, my hand doesn't hurt, and I personally feel it is a safer option (in a CYA aspect).
  4. by   SorenDrake
    Oh, one other thing. Our bedside monitors link to the charting system, so you just have to verify the vitals! Only a few things can't link, such as continuous cardiac output and IABP readings.
  5. by   cvryder
    I've used several computer charting systems over the last few years in different hospitals. Some are pretty good, others seem to have been written by aliens. At a couple of hospitals I've used one called CareManager that is pretty user-friendly, although one hospital managed to louse up their med administration computer charting pretty badly using the same program. Another was only partially computerized, for orders and labs, using a program called LastWord, which I can only characterize as primitive, clunky, and horrible. Thank goodness we were still paper charting our patient care. The place where I am finishing an assignment now actually uses two systems. For our "regular" charting we use something called IDX, which is a sort of "son of LastWord". It's functional but not terribly user-friendly, particularly in the area of documenting assessment. Because all the hospitals in the system share a "remote ICU" for critical care areas, vital signs and some other information are documented in a different program called VSICU. This is linked to our monitors even to IABP etc. There is now some talk about whether the system will go to documenting everything in VSICU. It would make more sense to me than what we are doing now, which is suspiciously close to double charting. We also have to handwrite a progress note in the paper chart, which seems to me like a relic of the past.
  6. by   moonshadeau
    Quote from cvryder
    I've used several computer charting systems over the last few years in different hospitals. Some are pretty good, others seem to have been written by aliens. At a couple of hospitals I've used one called CareManager that is pretty user-friendly, although one hospital managed to louse up their med administration computer charting pretty badly using the same program. Another was only partially computerized, for orders and labs, using a program called LastWord, which I can only characterize as primitive, clunky, and horrible. Thank goodness we were still paper charting our patient care. The place where I am finishing an assignment now actually uses two systems. For our "regular" charting we use something called IDX, which is a sort of "son of LastWord". It's functional but not terribly user-friendly, particularly in the area of documenting assessment. Because all the hospitals in the system share a "remote ICU" for critical care areas, vital signs and some other information are documented in a different program called VSICU. This is linked to our monitors even to IABP etc. There is now some talk about whether the system will go to documenting everything in VSICU. It would make more sense to me than what we are doing now, which is suspiciously close to double charting. We also have to handwrite a progress note in the paper chart, which seems to me like a relic of the past.

    LASTWORD, what a horrible system...:crash_com
  7. by   RNforLongTime
    Unfortunately, I don't see my hospital going to computerized documentation for a LONG time. Right now, everything that we do is written out by hand. EVERYTHING! Lab slips, dietary orders, nurses notes, the whole caboodle. Xray requests frequently mysteriously get "lost" then I get yelled at by the docs because Mr X didn't get his CT scan.

    The last hospital I worked at was completely computerized and I loved it!

    So, I'd like to revise/revamp our current ICU graphic flowsheet. If anyone still uses paper charting, I'd love to see some examples. Thanks!
  8. by   RNforLongTime
    Btt

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