Starting in a new MICU

I am a newer nurse, so I can't speak to how things used to be, but I also work in the ICU and can say that the charting/documentation is crazy. I definitely spend more time charting than with patients, and I have been told by co-workers that I chart really fast. It just unfortunate that we live in a society so quick to sue for everything, so instead of building good rapport with patients we just cover our butts in heaps of documentation. It's sad.

I agree with you. Things have changed and paper charting was quicker if you ask me.

Documentation is now tied to reimbursement by Medicare/Medicaid. The computer systems were not designed for the end users, they were designed for the people who audit our charting to make sure that we are fully compliant with all required.

Unfortunately time is finite, so corners have to be cut somewhere.

My hospital stopped hiring secretaries. CNAs are crosstrained to cover the duties of the secretary. The CNA work keeps them busy enough and rarely sitting down, so the phone is catch-as-catch can.

Maybe in the future the charting systems will become more user friendly. I have a collection of vintage nursing books. My favorite picture is one of nurses doing their charting in the 1950s. All the chart for each patient fit on one clipboard.

I remember the clip board days. Though, by the time I started charting it was a lot more intense!! Then came the lawyers... Look at us now. Very sad:( We need Tort reform!!

I wasn't a big fan of computerized charting when I first encountered it. In the intervening fifteen years or so, I've found that it saves time -- or WOULD save time if they didn't keep adding MORE things to chart on to cover behinds as MORE lawyers get involved. Now I'm glad I don't have to chart on paper. Once you (the OP) get the hang of it, you may find that you actually like it. I'll keep my fingers crossed for you anyway!

We have tort reform - with limitations on malpractice claims - but it doesn't make any difference in the paperwork. Everything is linked together now, so all of the data needed for other processes (billing, supplies, quality, risk, etc) is based on nursing documentation in the EHR. CRAZY!!! Every time a new requirement comes up, the nurse gets stuck putting in more data.

I miss the old random access hardcopy records (AKA paper charts) also. In my idealized world, nurses wouldn't have to document at all... just wear 'Google glasses' with audio recording capability while we perform patient care. What would we do with all that extra time???

I actually like ours. It was VERY intimidating at first, but it got better w/ a little practice.

My last job was in a small LTACH, and they were starting to transition to computer charting. We had an eMAR, paper flowsheets, and we double charted our VS, I&Os, and sepsis screens; we had 4-5 pts on the floor, 3 in the ICU. I hardly ever got out on time b/c of charting.

But I am sorry you're having a rough time. Hugs!! I hope it gets better soon.