Resus/Trauma charting in Meditech

[cerejanebellum, BSN, MSN, RN]

Hi friends :)

Just wondering if any of you are working in departments currently using Meditech, and if you're using it to document Resus/Trauma situations. We have a triplicate paper form that has to be filled out for true arrests/traumas but what about very unstable patients (in Canada we'd call this CTAS 1 or 2)... would you still be on paper for those?

How is it documenting in Meditech in the ER? I'm wondering if you've developed any good tips or insights?

Happy Nursing :)

[meanmaryjean, DNP, RN]

I just want to express my sympathies for the fact that you're stuck with Meditech....

[JKL33]

"Way back when...", my charting used to be meticulous. It was meditech that made me stop all of that nonsense. Okay, seriously, with any charting system, if I can't easily and quickly find and click exactly the right box that says what I want to say, I right click to add a quick/concise note. I'm not clicking a box for every separate lung field etc., etc., or adding 20 different 'occurrences' or whatever, just to be accurate. With critical patients and meditech, I tended to put in an initial assessment and then use notes for the situation as it evolved. Not ideal, but to me it is more accurate and actually faster than the search-and click malarkey.

I know people tend to despise narrative charting these days, and some don't know how to do it. But in my own defense, possibly THE main reason I do this is because if I ever need to look at it again, I will be able to make sense of it and know precisely what was going on and what I did about it. Sorry I don't have a better/more detailed answer.

[Lunah, MSN, RN]

Meditech is not trauma/resus friendly — I would actually lean towards "hostile," lol. The only place I have done trauma documentation in the EMR was using Epic. We have Meditech (not even the newer version) and our traumas/codes are on paper.