Need New Ideas, CHARTING

doodlemom · Jun 16, 2005

WOW! Your nurses have it made! It sounds like an expensive system, though. How do you get notes into facility charts? Most facilities want notes left when the visit is made. We used to do all of our documentation on paper notes and meds were entered into the computer by office staff, but now we use a computer system and we all document on lap tops - entering our own orders. Paper charts were easier and quicker but it's also convenient to always have current info.

rockchalk_jayhawk · Jun 16, 2005

wow! your nurses have it made! it sounds like an expensive system, though. how do you get notes into facility charts? most facilities want notes left when the visit is made. we used to do all of our documentation on paper notes and meds were entered into the computer by office staff, but now we use a computer system and we all document on lap tops - entering our own orders. paper charts were easier and quicker but it's also convenient to always have current info.

all our notes are transmitted to our coverage facilities. they will get them the day they are transcribed or the following day if there are corrections to be made. and at times they will still get them the same day.

what program do you use for your charting and doing your own orders? do you just use a word processing program or something specific?

doodlemom · Jun 18, 2005

We use Suncoast Solutions. It's probably the best hospice software out there, but it is still pretty user unfriendly and has a lot of kinks

Katillac, RN · Jun 20, 2005

hello all, and good day
at this time my nurses do their charting by dictating into a dictaphone and a transcriptionist types it. this can be, at times a costly way of charting if the transcriptionist has to type the dictation several times after being reviewed by the nurse for corrections. this is the system that was in place when i became the director 6 months ago. i am now being pressured to find alternative ways to do our charting. i know there are many different methods out there.
i want to know what has worked for you? what do you like? are there any excellent suggestions (i'm sure there are)?
please help. i will take any and all suggestions, at this point.

my goodness, i am so jealous that your nurses get to dictate their charting! we use suncoast as well at out hospice, and i agree with the characterization of it as being not very user friendly, but the best i have seen.

as you consider the cost of implementing a new system, you might consider what it will cost to implement and run a specialty software system. make sure you include:

software startup cost
hardware with frequent upgrades
paid hours to train staff with new software
the amount of time (money) it will take to get new clinical staff trained due to the huge learning curve in handling a very specialized system of information entry
fees paid to software company for training
and the fact that not all nurses will be able to adjust to your new system; some of your best could end up leaving over it.
who will you have on staff that can address tech issues? (the server goes down and won't reboot, you have a conflict with a new patch and your laptops won't interface with the server, etc) some things can't wait until a part timer, for example, is available to fix it. we have an admin who is a stone wonder with suncoast. she has done major customizations with it, but she has the talent for it.
our nurses do, in effect, all of their own transcription. if your nurses need to spend many additional hours on documentation, their productivity in the field will be affected. consider that with the cost.
we are being pushed to take our laptops into patient homes. do you really want your hospice nurses looking at a keyboard and trying to fit their patients into the system offered rather than looking into the eyes of these dying people? the tech stuff gives the bean counters the opportunity to have the clinical staff do their work for them. it's more momentum in a system that pulls nurses away from caregiving and toward administration. be prepared for the consequences.

as you can tell, i feel rather strongly about this! :rolleyes: i'd be happy to chat further with you by email if you would like.

jerseyRN · Jun 22, 2005

Your comment about bringing laptops into homes is much appreciated. It's not practical, and it's rude. We also get told that bringing the laptop inside will cut documentation time. No way, Jose.

HospiceNurseDawn · Jun 23, 2005

We all use laptops. It is wonderful. I have one small bag for my laptop - and our laptops are loaded with software for driving/maps, drug info and flowcharts, all phone numbers you need, Outlook for scheduling and email, almost everything you can think of. We even have an application that calcluates weights from mid arm circumference. As far as a laptop in a home - I think my patients feel very comfortable with the idea. Anything can be invasive if you let it. I have worked for companies that were paper only and going into a home felt like I was a pack mule with my heavy binder and misc papers.

We are switching to a handheld pc this fall - Homecare Homebase is the name of that program I think.

Good Luck -

Dawn RN

OneThunder, BSN, RN · Aug 5, 2005

We all use laptops. It is wonderful. I have one small bag for my laptop - and our laptops are loaded with software for driving/maps, drug info and flowcharts, all phone numbers you need, Outlook for scheduling and email, almost everything you can think of. We even have an application that calcluates weights from mid arm circumference. As far as a laptop in a home - I think my patients feel very comfortable with the idea. Anything can be invasive if you let it. I have worked for companies that were paper only and going into a home felt like I was a pack mule with my heavy binder and misc papers.
We are switching to a handheld pc this fall - Homecare Homebase is the name of that program I think.
Good Luck -
Dawn RN

yes,I agree, anything can be invasive if you let it. I use my palm pilot/cell phone with a pda patient tracker program in it. It ismy personal program. But the paper is all there. We need to find a balance. Perhaps a small amount of paper that certain info can be entered into the laptop for updates? What the software companies need to do is shadow a case manager for a week or two-and see what they really need as opposed to what the office staff says they need. Transmitting information to a facility is okay, but what about home patients? I make a visit, I don't like to come to a case cold and not have the information available to me. Laptops would help you access the entire patient chart. You could even have some programs that trend things like vitals signs, weights. But they have to PROMISE to reduce the paper. Stop killing the trees. LOL :plonker2:

Carlos Casteneda · Aug 7, 2005

hello all, and good day
at this time my nurses do their charting by dictating into a dictaphone and a transcriptionist types it. this can be, at times a costly way of charting if the transcriptionist has to type the dictation several times after being reviewed by the nurse for corrections. this is the system that was in place when i became the director 6 months ago. i am now being pressured to find alternative ways to do our charting. i know there are many different methods out there.
i want to know what has worked for you? what do you like? are there any excellent suggestions (i'm sure there are)?
please help. i will take any and all suggestions, at this point.

in england in general we dont have computers for charting we are still using integrated care pathways the lcp is however quite effective for recording the terminal phase of someones illness i could post a copy if you are unfamiliar

julian

AtlantaRN, RN · Aug 7, 2005

our hospital (piedmont in atlanta) uses quest, a online software program, we'll start online charting next year (we still do it the old fashioned way, writing it all out by hand), we started this year by accessing labs and er reports online as well as diagnostics/radiology, mri, etc.

not bad for fayetteville GA location as only last year our MRI was brought in 3 days a week in a TRUCK!!!

atlantarn