compuer documentation

  1. We are going live with Cerner computer documentation in a couple of weeks. We currently chart our assessments every 30 min. When we go live with the computer documentation some staff are saying that they are only going to chart their initial assessment and only go back to chart any changes that may occur. How are other PACUs that use computer documentation charting their assessments?
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    Joined: Mar '09; Posts: 5; Likes: 3

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  3. by   All4Seasons
    We've been working with an Horizon computer program for ~ 2 years in our PACU. Because the bright minds in charge (and not at the bedside) didn't procure a program which interfaces with our moniters,we fought for and won the fight to keep our paper graphic records -that's where we chart our q 15 min v.s. (or more often,if needed). We thought it insane to computer chart v.s. every 15 minutes with another pt to care for as well. We are (almost) promised the $150,000 we're told it'll take to connect our computers to our moniters. Hope it comes in my lifetime.
    All of our other checks - csm/drsgs etc are charted q 15 min depending on the case/complications-then I move the checks to q 30min when I deem it appropriate.

    Wait a sec...you probably mean the PACU discharge assessments!? Ours are first done based on the initial set of vitals then q 30minutes in one specific area of the chart. Out of 10,the five categories are drop down boxes,horizontally placed, with scoring 0-2. Once you get to a check with a full score of 10 you don't have to fill in the '2' in each of the 5 boxes -just the '10' in the total score box - but we do chart the score q 30 minutes to indicate that we assessed the pt every half hour,as per the national standards. I don't think it'd be fully complete charting if one didn't show an assessment had been undertaken q 30 minutes...it allows room for questions to be asked about the care - I'd worry about that in a court proceding.

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