ranchand

We have got the basic format down and we are using med-tech. what i am looking at is what is being used for the normals and how it is being applied to medical records. On things such as labor progression how dose the DR know where you are in the proses es if nothing has charted out of normal? I see that if you set the normal limits narrow it would work but how broad can you set them with out opening those charting up to law suite??

I am one of a small team of RN's at our Hospital doing a nursing redesign for our med-tech computer charting we are trying to make the hole H&P and daily Physical as well as the OB daily Physical. charting by exception. Dose any one out there have a model for such a thing would love to ask questions about or maybe even come to see how it works for you. Any help would be great thank you in advance. Ranchand RN:balloons:

I really dont have much to say on the subject as I am a snurse:)) and still have not done my med surge. However I did have a surgery in billings MT in which such a prep was used. There as no tint in the prep and the hair was taken to just about one inch above my umbilicus. :)) I will watch this thread for more info as how u work this out sound like it could be very usfull information for nurses in any field. :)) will also ask at our hospital and see what they have to say one the ??