Jump to content

Paper charting in acute care

Nurses   (1,406 Views 5 Comments)
by sjalv sjalv (New Member) New Member

sjalv has 1 years experience and specializes in CVICU.

12,022 Profile Views; 897 Posts

advertisement

Hi

I wanted to see what other nurses deal with as far as paper charting in the hospital setting. I work in an ICU and things such as medication orders, certain admission things like core measure checklists, admission skin assessments, progress notes by physicians, etc are still written. We have been 'in transition' to electronic charting for about 6 months now. We have computerized physician order entry, but some physicians will still write paper orders like 'H&H stat once, then q12h after', 'Start patient on electrolyte replacement protocol' (

However, we can't put medication orders in, only things like labs or radiology studies, so getting a telephone order at night like '15mg Restoril PO QHS PRN sleep' would have to be written down, signed TORB /

We still have a lot of written protocols that have to be filled out (like for blood sugars, what frequency should bg checks be done? what slide should insulin dosage be based on?), or electrolyte replacement where we indicate which electrolytes the physician wants to be routinely replaced, what the patient's weight is, and of course affix a patient lab and scan it down to pharmacy.

Our actual charting is all electronic; we only do paper charting for assessments etc during downtime. But physicians only use CPOE half of the time, and only dictate their notes half the time. I can't read the progress notes most of the time, and sometimes a written order is illegible from the previous shift and you can't get a hold of that physician because s/he isn't on call to clarify it.

Is this the norm? It just seems antiquated in the year 2015/2016. For what it's worth, this is a big hospital corporation, not some small rural facility.

Share this post


Link to post
Share on other sites

hope3456 is a ASN, RN and specializes in LTC, Psych, M/S.

1,262 Posts; 20,167 Profile Views

Rocking in the same boat, friend. I work in a facility that still uses paper MARS and an outdated computer program for charting. I can't believe it's still legal.

Share this post


Link to post
Share on other sites

TheCommuter has 10 years experience as a BSN, RN and specializes in Case mgmt., rehab, (CRRN), LTC & psych.

228 Articles; 27,607 Posts; 316,485 Profile Views

The smallish specialty hospital where I worked for five years made the complete conversion to electronic charting in late 2013. Everything (H&P, orders, nurses notes, discharge planning, plan of care, MARs) is computerized.

Share this post


Link to post
Share on other sites

Pixie.RN has 18 years experience as a MSN, RN, EMT-P and specializes in EMS, ED, Trauma, CNE, CEN, CPEN, TCRN.

32 Articles; 13,028 Posts; 127,051 Profile Views

I work for an Army hospital, and our ED is still on paper. Yep. Ironic, considering all the GOVERNMENT requirements to be electronic! We'll go to Cerner... right around the year 2020. Lol.

Share this post


Link to post
Share on other sites
  • Recently Browsing 0 members

    No registered users viewing this page.

×