Computer Documentation of Nursing Assessment, Time Saver?


This is a question recently asked by many in the medical center where I work. We are currently switching from 3 separate computer documentation/ order entry systems to one single computer order entry/ documentation system which will be accessible to all MDs and nurses. This, in theory, will be an excellent answer to a nurses constant struggle to find enough time at the bedside. As more medical mistakes are made, and as a result, the legal system, DHS, JCAHO, and other such governing organizations become involved in our patient care, nurses see an ever increasing amount of documentation… the dreaded paperwork. Computer documentation is a brilliant answer, so long as nurses can remain open to possibly learning new technology and devote time to become faster with computers, if needed. However, I see with the transition in my hospital that a nurses input is essential in this form of documentation. Our current computer system often requires double and triple documentation. So, as the nurse should have increased time at the bedside due to their supposed decreased time documenting, we find that nurses have even less time at the bedside and as much, if not more time documenting than before. I see computer documentation as necessary in our current age and incredibly beneficial in MD/RN communication, redemption of lab/ test/ procedure results, dictations and other medical records, however, there is still so much room we can grow in the region of nursing and informatics. I often feel as though those developing our computer resources have not recently spent time at the bedside, if they had I feel we would greatly minimize the double and triple documentation we are required and use technology to our advantage in opening up more time for bedside care.

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