Tell us about your computer system

Posted
by Brian Brian, ASN, RN Member Innovator Expert Nurse

Specializes in CCU, Geriatrics, Critical Care, Tele. Has 28 years experience.

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laurasc

laurasc

Specializes in Gen Surg, Peds, family med, geriatrics. Has 26 years experience. 306 Posts

I work in a pediatrician's office and we run a medical records program called "MacMedical."

There's the actual patient charts, which is called MacMedical Records, or MMR. We do all of our charting on the computer. Test results and typed letters can be scanned into the system. Hand-written consults and letters have to be stored in the paper charts. It's working alright now, but it was rough at first. The most tedious was transferring records such as vaccination dates and PMH to the computer...something that I had to do most of.

The system also includes a complete billing and scheduling system.

We have a computer in the examining room, in my office, the doctor's office and two in the reception area. The nice thing is that I don't have to run to the reception anymore when I want to schedule a patient for another day.

Laura

toronto rn

toronto rn

91 Posts

The hospital I work at started using computer charting last year. The actual flow sheets used on the program were developed by the nurses, and are still undergoing revision, but the initial aches and pains are pretty much overwith. All the monitors ventilators and iv pumps are integrated into the system which allows you to just click and download all your VS and Vent signs. The integrated system will store minute by minute information for 72 hours allowing you to chart late entries with real time information. Downfalls I've noticed is that it is not as easy to retrieve info. (as a flow sheet would be) I have not yet learned to like charting by exception. It is timesaving to have labs and orders accessible at the click of a mouse. Big downfall is I find it more difficult to remember information about the pt ie last bp vent signs etc. The loss of physically writing things down seems to make it more difficult to recall, as a result I still tend to keep a mini flow sheet in my pocket for jotting down this kind of info, so much for paperless!

Y2KRN

Y2KRN

216 Posts

Miss the electronic charting. I am a new nurse and my first job I took just implemented computerized charting. It was a great time to start because the staff was learning the system as well. We used the CPSI system, now I work at a facility that still hand charts. Our computers had touch screens and you could chart by exception. The only draw back was the MAR's however at the time they were troubleshooting the difficulties and I am sure by now they have been worked on and improved. I miss the admission part the most there was not 50 different papers to fill out for the admission process.

PedsRN3

PedsRN3

3 Posts

I'm a float in a children's hospital and there are 3 types of computerized charting that are used in the hospital--Meditech on the inpatient floors and OR, the Marquette QMI(?) system in the ICN and another used in the ER (I don't float there so I don't know the name). The PICU continues to use paper charting while deciding which computerized charting to go to.

I have used both MEditech and the ICN systems extensively and I like each for different reasons. The ICN system is nice because the vitals automatically "drop" into the charting at specified intervals. You also don't do any lengthy patient notes, everything is down with a "pull-down" menu. It is also a plus to have all the social work and discharge planning on this system too....makes for much easier discharges. The one thing I don't like is that we still have to use MEditech to do "order entry". Meditech is nice because everything is right there...your assessments, social work notes, lab values, etc.

We still have paper charting for everything the MD does....we were told this will eventually change. With our med orders we also use a paperless system....our orders are scanned down with the Pyxis system and the pharmacy completes the orders.

I do not like that the PICU is still using paper charting because after the pt is transferred to the floor we have no real way of looking up assessment trends without going through the paper charting....we don't have that information "at a glance".

Overall I really like computer charting....don't ever want to go back to paper charting!!! :)

mjamesRN

mjamesRN

62 Posts

I looked through all the posts here and didn't see the computerized system we use at my hospital -- It's called TDS. It's an archaic system at best but the nurses chart all meds given and the care plan is initiated through it. Daily we have to review all the goals and protocols for the patient, delete and/or add to it. This ensures that all goals for the patient for the patient have been reviewed and implemented up until their discharge. It's a good system, but we still have to chart on a flow sheet and document pain management by hand. The upside to this is that physicians MUST use it to enter orders (so we don't have to decipher poor handwriting). The downside is that you can't rely on it entirely because there still remains misspellings and omissions on patient data. I think we're upgrading to a Microsoft system this year.

tntrn

tntrn, ASN, RN

Specializes in L & D; Postpartum. Has 34 years experience. 1,340 Posts

I would love some feedback from others who use (and like or don't) computerized charting. We are in the beginning stages of using Watchchild in our OB unit. For the most part, I really hate it.

Part of that is because ergonomically, our facility is not ready for more equipment in our rooms, so our mouses are placed on mousepads that fall over the edge of the allotted space, the monitors and/or keyboards are not adjustable in height so nurses are either leaning over or craning their necks to use one or the other. In one room, the keyboard is so low, I stand on my knees to use it, and I'm 5'2"! I just wish OSHA would wander in.

That being said, I also don't like it because I think it really detracts from patient care. If you're doing fetal scalp stim and the computer needs you to "acknowledge" a low heart rate, are you really going to do that? I won't. The computer is not my main concern.

Now my question is this: recently when I came on shift, a NST test was just being completed and it was left to me to discharge the patient. I was in the process of doing that when another nurse charted (electronically) that I had interpreted the strip. That, in fact, was so and I wouldn't have discharged her if I had not, but I'm not comfortable with the idea that someone else can chart something I did. What are the legal ramifications if that nurse charts something I didn't do, or charts it incorrectly, or what if I wasn't even there or not caring for that patient?

I put that question to our nurse manager last night and she said that IF the chart were reviewed that kind of information would come out. Well, only some charts are reviewed so what if it goes to court in several years. I'm just not happy with that part of it and that's why I don't print my name using the computer on any of the screens. Rather, I print out the form (right now we're only using the admit form and a form for outpatients) and then I hand-sign the form.

In addition, I am not comfortable with going all electronic because you'll never be able to see all your "charting" at one time. It just doesn't make sense to me, and I'm hoping to retire before it really gets to the point where we are spending most of our bedside time pecking away at a keyboard, either at the bedside or at the nursing station.

Can you tell I'm an old broad? HAHA!

Marijke

Marijke

Specializes in Obstetrics, perioperative, Infection Con. Has 25 years experience. 122 Posts

My hospital is very computerized and all our charting in the OR is done by computer. There are some good things about it, but some very bad things. The good thing is the way it forces you to be accurate in a lot of things if you leave a spot open, it will come back to hunt you, if you missed something you don't have to go to the ward or medical records to change it, you can do it from any of the many terminals in the hospital.

The drawbacks are, the length of time it takes to chart, there are 7 screens to complete which can take a lot longer than writing the info on paper, especially for short cases or if you are very busy assisting the surgical team, with supplies etc. It tends to take you away from patient care, since you have to turn away to do the charting.

Another hard thing is sometimes finding the correct procedure performed amongst the many procedures stored in the computer. Especially when it is something unusual. When you chart on paper, you just write it down, even when it is unusual, in the computer you have to find the exact procedure when it doesn't excist you find the closest thing and write a note regarding the unusual circumstances, this proces can take several minutes.

I also hate it when labwork is ordered, it means I have to get out of my operating room record and go through several steps to enter a requisition, lots of fun especially when you are in a hurry with a heavily bleeding patient in your room in the middle of the night with no unit clerk. The lab for example will not release any blood products without a requisition in the computer to release a certain product.

The positive point for our computer system, is the in hospital e-mail system. Things are communicated very well, everything you need to be aware of is send to you by e-mail, no communication book to find (which goes missing a lot anyway). All policies and procedures are also in the computer, which means I can find them without leaving my room.

oneLoneNurse

oneLoneNurse

Specializes in Psych, Informatics, Biostatistics. Has 25 years experience. 613 Posts

OK, which package is it ? Just curious.

And speaking of labs. At our hospital if the order is written for an ER patient( nurse drawn) and the patient gets transferred to a med/surg floor(lab draw) NO pick up sheet gets printed for that patient because the order was written while the patient was in ER(nurse drawn). This is an ongoing problem.

My hospital is very computerized and all our charting in the OR is done by computer. There are some good things about it, but some very bad things. The good thing is the way it forces you to be accurate in a lot of things if you leave a spot open, it will come back to hunt you, if you missed something you don't have to go to the ward or medical records to change it, you can do it from any of the many terminals in the hospital.

The drawbacks are, the length of time it takes to chart, there are 7 screens to complete which can take a lot longer than writing the info on paper, especially for short cases or if you are very busy assisting the surgical team, with supplies etc. It tends to take you away from patient care, since you have to turn away to do the charting.

Another hard thing is sometimes finding the correct procedure performed amongst the many procedures stored in the computer. Especially when it is something unusual. When you chart on paper, you just write it down, even when it is unusual, in the computer you have to find the exact procedure when it doesn't excist you find the closest thing and write a note regarding the unusual circumstances, this proces can take several minutes.

I also hate it when labwork is ordered, it means I have to get out of my operating room record and go through several steps to enter a requisition, lots of fun especially when you are in a hurry with a heavily bleeding patient in your room in the middle of the night with no unit clerk. The lab for example will not release any blood products without a requisition in the computer to release a certain product.

The positive point for our computer system, is the in hospital e-mail system. Things are communicated very well, everything you need to be aware of is send to you by e-mail, no communication book to find (which goes missing a lot anyway). All policies and procedures are also in the computer, which means I can find them without leaving my room.

LilRedRN1973

LilRedRN1973

Specializes in ICU, psych, corrections. Has 8 years experience. 1,062 Posts

I work at a large teaching hospital in a Trauma/SICU/MICU with 36 beds (they are split into two different units...one being SICU/MICU and other other Trauma with SICU/MICU overflow). We use the QMI (QS) system and I love it. I HATE the computer charting they use in other parts of the hospital. I'm not sure what it is, but it sucks. The QMI is easy to use, easy to point and click, yet also easy to annonate when there is no choice that suits your patient. There is a place for Interdisciplinary Progress Notes where the RN's can chart progress notes should they chose. I always go back and read through at least the previous shifts notes, if not further back so I can get a clear picture what's going on with my patient. How nice it is to be able to read the notes and not spend hours trying to decipher people's handwriting (like my own chickenscratch).

My only complaint? It doesn't seem as though the physicians read the notes which makes me wonder how they are getting the information about the patient's condition, except the moment here and there when the RN is able to tell them face to face or the occasional phone call. I know in other parts of the hospital where they still do the paper progress notes, physicians actually do look over them. But I have never seen an MD looking through the computer charting....hell, half of them play stupid and ask you to log on and print out face sheets, reqs, labs, etc.

But overall, I really enjoy the computer charting....I'm a computer geek myself and would much rather type stuff than have to write. I have crappy handwriting and it takes me FOREVER to write what I could've typed in seconds. The system can also be easily be updated to add and subtract things that the RN's feel is necessary. We have a Shared Governance meeting on a regular basis and that's where it's determined if anything needs to be changed. I would like for them to notify the rest of the unit when they change stuff......LOL....I will be charting, see something new, and think "when on earth did that get put in there??".

Melanie = )

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