Ponder this question, DON couldnt answer..

[Ricu]

I kind of like electronic documentation systems myself. Seen a few really good ones that cost too much; used several not-so-good ones that cost less. I don't like to write since my penmanship is terrible and while dictation saves the "dictator" time, it's difficult at best to transcribe. Have you seen the transcription error emails? What a riot! Anyway, I suppose there's no perfect system.

R

[Reneec]

The electronic age is only as good as the electricity that is supplied. My mom, may she rest in peace, had her last hospitalization charted on computer, and when the computers "went down" so did all the info. No one knew if she had had a bowel movement recently, needed an enema, was due for medication, and the list goes on and on. Give me those old reliable paper charts anytime. It sounds like you all have some wild stories to tell. I came across an interesting site recently for sharing experiences and read a cute one about a super nurse. If you're interested you can read it at this link: Care2tell - A Shot in the Park
In the meantime I'm enjoying my retirement and reading all your stories. It brings back good memories.

[stellar]

We know the pitfalls and advantages all computerized systems bring, but keep in mind there has been a proposed governmental bill floating out there that wants all citizen's medical history concisely available in electronic form, in order "to save money"??? I cringe at the nightmares in confidentiality and technical gliches this could bring if passed. We had a guy here in FL who had a fight with his S.O. who worked for the Dept. of Health and put the names of HIV pt's he had in his possession online....He got caught, but too late for the patients.

[Ricu]

Good thing that we have vindictive people without conscience in the world, huh?

R

[cougarnurse]

Puts new meaning into 'Big Brother' is watching. One problem with electronic charting is possible corruption of data, I think. Some of the dictated stuff I've seen are filled with holes.....

I say chart by exception.

[LivingDeadNurse]

Originally Posted by BeachyCEN

]All I can think of is, if it is not documented, it's not done...learned that in nursing school [/COLOR]

yes but do we have to document the same thing 3 or 4 times? for instance FSBS it prints of a paper and we put it in the lab section, we have also charted in the MAR, the nurses notes and on the 24hour report? really is all that nessecary? i would rather spend my time with my patient. its heartbreaking being in long term care when you can' t take the time to really see how your pt is doing by having an actual conversation

[Reneec]

I can only imagine how frustrating this duplication of effort must be. There must be some bright "techie" out there with a solution to the problem of how to record it only once yet get it distributed to the proper destinations--Morse code?

[LivingDeadNurse]

Originally Posted by Reneec

I can only imagine how frustrating this duplication of effort must be. There must be some bright "techie" out there with a solution to the problem of how to record it only once yet get it distributed to the proper destinations--Morse code?

hmmm don't give them any ideas like that lol

[Ricu]

Ya know, I think the biggest pet peeve that I have about nursing is the insane amount of documentation that is now considered essential. I realize that these are my personal observations but I've been doing this for a long time and have seen the changes. Let's see where it comes from now... We have the bureaucratic, government driven,machine, JCAHO; morphed to out-of-control proportion in response to the bigger machine- the healthcare insurance industry. Their tactic; let's hold reimbursement hostage till you comply or my favorite- we'll send out the chart auditor to fine-tooth the record and look for any possible reason to decline payment. You can be absolutely sure they'll find one.

Then there's the less popular, paranoia driven, "I need to write everything down or else" reason for senseless documentation. I find crap like "Patient observed to be resting in bed with three rails in upright position watching television from 1400 till 1545, at which time he rang the bell to get up to void 400ml of clear yellow urine without difficulty, at the bedside, into the urinal. Patient assisted back into bed safely and rail returned to upright position". Thank you very much, Jim Sokolove, and all of your fellow bottom feeder, opportunists who use greed and entitlement to generate many pointless lawsuits.

Okay, okay, I'm off my rant now but see what I mean?

R

[LivingDeadNurse]

Originally Posted by Ricu

Ya know, I think the biggest pet peeve that I have about nursing is the insane amount of documentation that is now considered essential. I realize that these are my personal observations but I've been doing this for a long time and have seen the changes. Let's see where it comes from now... We have the bureaucratic, government driven,machine, JCAHO; morphed to out-of-control proportion in response to the bigger machine- the healthcare insurance industry. Their tactic; let's hold reimbursement hostage till you comply or my favorite- we'll send out the chart auditor to fine-tooth the record and look for any possible reason to decline payment. You can be absolutely sure they'll find one.

Then there's the less popular, paranoia driven, "I need to write everything down or else" reason for senseless documentation. I find crap like "Patient observed to be resting in bed with three rails in upright position watching television from 1400 till 1545, at which time he rang the bell to get up to void 400ml of clear yellow urine without difficulty, at the bedside, into the urinal. Patient assisted back into bed safely and rail returned to upright position". Thank you very much, Jim Sokolove, and all of your fellow bottom feeder, opportunists who use greed and entitlement to generate many pointless lawsuits.

Okay, okay, I'm off my rant now but see what I mean?

R

hey when did you read my charting??? lol