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"Nurse's Notes versus Paperless Documentation":

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Posted about 3 years ago

 

       " Recently, I had responded to an on-call assignment @ a local LTC facility,where they had recently


         adapted," paperless documentation".During the course of the shift, I was given a temporary,password


          for visiting,licensed staff to utilize for charting>which failed to take to their computer system.


          The * Help Desk voicemail did not respond ,either.After my shift was completed,


          I documented pertinent information for the day,in charts,**using handwritten,Nurse's Notes.


          When I inquired about having my timeslip signed by the RN, I was sent to the DON's office.


           ***They insisted on **paperless charting> refusing to authorize my hours that I had worked.


           I met with the,"powers that be",remained very calm, soon thereafter, acquired credit for a job well done.


           This circumstance was reported to the appropriate personnel / private contractor.


             **Any thoughts on this matter?"

Chi_chi_doing_a_head_dance_006_max50

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Rate This | Posted about 3 years ago

 

my facility. just adopted papperless charting and there is not a day that goes by that we don't have a problem. We went from one sheet of paper to to seven screens for mulitiable entries, very time consuming. This was to free us, so that we had more time for our patients...what a joke


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Rate This | Posted about 3 years ago

 

more free time is what was promised when using the computerized charting ahhh yes


not true!!


the only thing good about computer charting is that you can alter the font and color and size of the letters!! i frequently chart my notes i hot pink 3 inch letters!! very snazzy

Pict0031_max50

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Rate This | Posted about 3 years ago

 

i think if the computer system is new than they prob. need to work out the kinks. i know that everytime we get an update to our computer system it takes time to work things out-they make changes as they go. we went to a whole new system earlier this year and it was chaotic for the first month at least.

Imag0115_max50

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Rate This | Posted about 3 years ago

 

   My facility has also adopted the paperless charting per computer. The thing is we on all 3 shifts cont. to do a skilled nursing note as well. It's crazy and most of the overtime is due to this double and triple charting.... I work dayshift 6 -2 and it's usually 4 or 5 before i get out of the facility. It's nuts and i'm worn out!!! I don't understand the purpose of paperless charting when we cont. to do Nurses notes!!

1024963740_m_max50

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Rate This | Posted about 3 years ago

 

Still charting on Interdisciplinary Notes (aka nurses notes) in a real chart. Problems abound especially when you have 30+ patients and 20 on charting.  The thought that you could check things off in the computer and write a short note sounds great. Unfortunately, I keep hearing about multiple screens and triple charting. Computerized charting is here to stay and since I first encountered it about 10 years ago, I don't understand why it has not become more user friendly. Obviously we need more nurses to go into the informatics field and help design programs that work for nurses.

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Rate This | Posted about 3 years ago

 

We've had paperless charting at my hospital for several years now and there are good and bad points. the bad is that instead of freeing the nurses to spend more time with their patients, it has chained them to the desk. The computers freeze or just shut down, and when they work they are slow. the MDs don't have access to the computer nurse's notes so they never read them, and the "funny bad' is that i thought computers would help nurses document clearly and "legibly" but the spelling errors are atrocious and no one seems to remember that there's SPELL CHECK! the positive, for me as the Nurse Manager, is that i have a computer in my office and don't have to wade through cumbersome charts, look for charts all day or try to decipher  illegible nurse's notes. I can access the patient screens and get info on everything the nurses input. They also do medication documentation via the computer. the patients many times comment that they nurses are "always on the computer."