Ponder this question, DON couldnt answer..

[Ricu]

hey when did you read my charting??? lol

I know. Don't you find yourself charting nearly the same things on each patient too? My favorite thing to write on our chart-by-exception flowsheet is "See electronic record" since we have to do both.

R

[Reneec]

As long as you guys can laugh about it, it can't be all that bad! Keep your sense of humor.

[cougarnurse]

Keeping a sense of humour....warped or otherwise....really helps. I figure if I can't laugh at least once a shift, something is inherently wrong somewhere.

[amberdouglas]

Maybe my attitude comes from always having done tons of charting but I would rather triple chart everything...
The way I look at it is, my professional liabilty insurance cost me less than 50 bucks a year, how much does a doctors cost?

[Ricu]

[QUOTE=amberdouglas;62740]Maybe my attitude comes from always having done tons of charting but I would rather triple chart everything...
The way I look at it is, my professional liabilty insurance cost me less than 50 bucks a year, how much does a doctors cost?[/QUOTE

I'd rather document only what's essential than to write volumes of extraneous, nonessential fluff. Writing more does nothing to minimize your liability in fact, it can increase it. Chart auditors have a field day with endless documentation. Write only what's needed and be concise besides, who has time to waste?

R

[OpensourceRN]

Interesting discussion. It looks like you all have tons of issues with the electronic end of things.
Technology is really about process and decreasing redundant documentation. If you are working on a system that doesn't help with that, then you need to get active with your IT department to find a better solution.

Count how many times and places vitals are documented (either on paper or in an e-chart)
Count how many times meds are documented?

So much redundancy in Nursing documentation and there is tons of research showing transcribing errors in nursing documentation.

that said, every e-chart should have redundant backups....so if power goes out, there should be back up power to switch over to, as well as a back up of the database regularly......

Sorry, TECHIE RN entered picture.........

:33:

[Ricu]

Interesting discussion. It looks like you all have tons of issues with the electronic end of things.
Technology is really about process and decreasing redundant documentation. If you are working on a system that doesn't help with that, then you need to get active with your IT department to find a better solution.

Count how many times and places vitals are documented (either on paper or in an e-chart)
Count how many times meds are documented?

So much redundancy in Nursing documentation and there is tons of research showing transcribing errors in nursing documentation.

that said, every e-chart should have redundant backups....so if power goes out, there should be back up power to switch over to, as well as a back up of the database regularly......

Sorry, TECHIE RN entered picture.........

:33:

Good input Opensource. Thank you.

I hold no fault with electronic documentation whatsoever in fact, prefer it. Now let's look at how those systems are built. I'm currently trapped in the "staged construction" of a system being done by our own IT department. I recognize that if the hospital would've just bought the product that we will eventually end up with it would've been a lot easier and considering the fleet of IT people running 24/7 in the place, no real money was saved but spent on salaries. Simultaneous to the never ending implementation of our nursing documentation system was our electronic medication administration record. Oh, and by the way, including lab and radiology reporting,none of the systems talk to eachother. Dollar for dollar, I think it's by far smarter AND safer to spend a million dollars on a comprehensive package, do one giant installation and get it over with because this "homegrown" crap takes an eternity to complete and then there's the support of it all. What a hassle.

Okay, I'm done now.

R

[amberdouglas]

[QUOTE=Ricu;62810]

Maybe my attitude comes from always having done tons of charting but I would rather triple chart everything...
The way I look at it is, my professional liabilty insurance cost me less than 50 bucks a year, how much does a doctors cost?[/QUOTE

I'd rather document only what's essential than to write volumes of extraneous, nonessential fluff. Writing more does nothing to minimize your liability in fact, it can increase it. Chart auditors have a field day with endless documentation. Write only what's needed and be concise besides, who has time to waste?

R

I never said I chart nonessential stuff, I said I'm used to triple charting...big differance. A good friend of mine is a Joint Commision auditor, so i always get to hear about whats right and whats wrong.
As for wasting time, I consider my charting as part of what I am supposed to be doing, not time wasted, becasue it IS what i am supposed to be doing...
The last time I had a chart audited, the ONLY thing they found wrong in my charting was I and O's were not totaled up and graphed...

[Ricu]

[QUOTE=amberdouglas;63182]

I never said I chart nonessential stuff, I said I'm used to triple charting...big differance. A good friend of mine is a Joint Commision auditor, so i always get to hear about whats right and whats wrong.
As for wasting time, I consider my charting as part of what I am supposed to be doing, not time wasted, becasue it IS what i am supposed to be doing...
The last time I had a chart audited, the ONLY thing they found wrong in my charting was I and O's were not totaled up and graphed...

Sorry Amber,

I didn't mean to imply anything about your personal documentation. I was generalizing. I guess I shouldn't have hit the "quote" button when I replied but your entry is what got me to thinking about all of the wordy, unessential, and sometimes misleading stuff that finds it's way into nursing notes.

R

[OpensourceRN]

Good input Opensource. Thank you.

I hold no fault with electronic documentation whatsoever in fact, prefer it. Now let's look at how those systems are built. I'm currently trapped in the "staged construction" of a system being done by our own IT department. I recognize that if the hospital would've just bought the product that we will eventually end up with it would've been a lot easier and considering the fleet of IT people running 24/7 in the place, no real money was saved but spent on salaries. Simultaneous to the never ending implementation of our nursing documentation system was our electronic medication administration record. Oh, and by the way, including lab and radiology reporting,none of the systems talk to eachother. Dollar for dollar, I think it's by far smarter AND safer to spend a million dollars on a comprehensive package, do one giant installation and get it over with because this "homegrown" crap takes an eternity to complete and then there's the support of it all. What a hassle.

Okay, I'm done now.

R

Ricu
Great points......Problem with IT today is that the vendors wanted to take hospitals (even for the last 20 yrs) for all their money, with very limited scoped products that were not fully baked or some that were even over baked (so many bells and whistles when all you needed were the fundamental capabilities)and you only get 5% utilization of the product because it is not user friendly and very complicated. An integrated solution makes sense for the most part, but vendors do not do "everything" perfect. Best of Suite often is a great way to move with technology.