Strategies to assist with real-time charting


  • Specializes in Neurosurgical, Orthopedic, Wound Care.

We are moving to Epic documentation later this year with computerized physician order entry. I have been practicing real-time charting for about a month now and it is challenging. I am looking for some tips to become more successful.

Currently we do not have computers in patient room, but 1 PC per 2 rooms outside the door. Adding computers and barcode scanners to every patient room is part of the plan for launch time.

I am trying to tell myself that everytime I walk out of that room there is something that I need to chart, whether it be an I/O or a PRN med I just gave.

Any tips, tricks, etc that anyone can share to make this transition more successful?

Specializes in Emergency; med-surg; mat-child. Has 5 years experience.

Fire it up when you walk in, then you can chart while you talk to the pt and do A&O. Do the physical, chart that (and you probably will chart by exception, so that's quick). You can't give meds without scanning (if you're following P&P, at least), so it has to be on then anyway. A lot of places have CNAs do the I&Os.

You really will get used to it. Lots more room to work with on a flowsheet than in a paper chart!