New Computer Charting, Having a Difficult Time w/ It

[SDS_RN, RN]

We just recently started computer charting and last noc was my 2nd day using the system and we got swamped. I had a hard time keeping up w/ my pts and my charting. I left there feeling like I was a terrible nurse to my pt's and very unsure if all of my charting was complete.

We are supposed to get our triage assessment in the computer and printed out right away for the docs but that was challenging because the waiting room was full + had 4 pts of my own out on the floor and it took me 2 hours to complete a summary on 1 pt because I could not sit down to get it in. It seems like there is a lot of double charting in this system and it seems to waste more time than our paper system did. They want us charting in the rooms but when it's that busy I don't have time to log in to the computer and enter info on several different screens. I was writing all this stuff down and entering it in later which was a mess. I was the 11-11 person and had charting to complete on 6 patients before all was said and done did not leave until about 0130. :uhoh21: It was so much easier w/ the paper system to get charting completed more accuratly and timely. I guess I'm just venting and wondering if anybody else has had this problem w/ computer charting and/or if you have any suggestions to keep up when the ED gets busy.

Thanks.

[EvilLiberal]

I work in LTC and so far we use paper charting. I can not imagine having to document ADLs and other things on 30 plus residents on a computer.

[akvarmit]

Don't be too hard on yourself! Switching from one system to another is a learning curve .....think of a big train rounding the "curve" on a mountain, only to shoot forward instead and down the ravine... Sometimes that's how it feels!

There is no way you can learn a new routine and not be slowed down. I'm sure the other staff is also struggling. I've done ER before, but I did the computer charting on the MedSurg floors and in HH, not ER, so I can't give you any tips there.

If you have access to computers in the nurses station, that can be your best bet. The "bedside" charting only invites continued conversation from the families while you say a vague ..."uh huh" and type away. You can't really pay attention if that's when they decide to tell you something important about gramma - because now your brain is in typing-mode.

Do you have an internal Informatics Nurse that you could call and see if she could go over it with you again? Sometimes there are "shortcuts" in the systems that aren't clear until more staff have used it. Like not having to "click out" to the main screen to get somewhere else......finding out you can jump around screens a different way helps sometimes.

Just be patient with yourself and let the patient's know you're trying something new and apologize for their wait.

It should get easier!

Dawn in PA

[mesa1979, BSN, RN]

We have been doing computer charting for quite some time, and you just have to slow down and put the info in. What helps me is to type the info in while talking with the pt. It takes a little longer until you get used to it and the pt's may have a longer wait, but you will find that it is faster than paper, and better. Once you get faster and more knowledgeable it'll be ok.

Good Luck!!!

[Dixielee, BSN, RN]

I disagree that it wil ever be faster than paper. I have been using computer charting in the ER for several years and it is still horrible. I spend much more time charting than ever, and less time with my patients. We still do our traumas and codes on paper, but everything else on the blasted computer. We use Cerner and if anything makes me leave nursing, it will be this.

I still feel like my charting is incomplete and does not reflect what has really happened with my patient. The docs input their own orders and many times we have to go back and re-enter, correct or completely re-do the orders. Many times we take verbal orders because no one has time to enter it at the time, and go back later and enter. It is just a disaster waiting to happen in court.

I will take care of my patients before I take care of the chart, but if it ever goes to court, I will not have a leg to stand on. What do I say, " I was taking BP's and titrating drips, hanging fluids, putting in lines, etc, but I didn't have time to chart each change". And we all know if you didn't chart it, you didn't do it.

I just pray that I can find another job where I don't worry as much about losing my license or worse because I was logging in and out of an unreliable piece of electronic equipment all day. I hate it!