Paper versus Computerized Charting


Computer Documentation

I have worked at 3 different hospitals; all had different modes of charting your assessments/admission information. The first hospital I worked at everything was computerized: medication administration, admission information, assessments, labs, orders, history and physicals, discharge notes, nursing notes, etc. All were in one system and any healthcare team member could retrieve the information they needed on a specific patient easily. If you had a patient that was transferred to you (I worked in the ICU) then you could review the nurse’s notes and see what had happened for their status to decline. Also when charting your assessment you could click the boxes that described how the patient presented in the exam but also at the bottom of each section was “other” where you could type anything that was not available in box form. It was very helpful and also much easier to read that physician’s and nurse’s notes (no messy handwriting).

The second hospital I worked at had online order entry system along with online lab results. All the assessments and admissions packets were paper charting. It was very difficult to use because a lot of it was redundant. It was also constantly changing because the cardiac floor would want something added then the surgery floor would need a section on incisions/drains. Many times there were things I found on my assessment but no appropriate box to chart my findings. In that case I had to hand write a nurse’s note about my assessment which they called “charting by exception.” The packets for admission were redundant but they were prepackaged and always readily available which was useful.

The hospital where I currently work is all paper charting. The lab prints their results to the floors’ copiers. The admissions packet repeats things up to 3 times. The paperwork does not allow you to assess certain areas of a patient. Like incision sites are terrible to assess with the paperwork and there’s no option for coarse lung sounds. Also the papers are in drawers and not put together in a packet form. This leads to missing paperwork on more patients than not. It has been a very trying experience, especially when I know there are such easier ways to document.

I very much prefer computerized charting/documentation. I believe that it leads to less documentation errors. I also believe that it is helpful for the healthcare workers to be able to access all the information they need in one place.

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One Response to “Paper versus Computerized Charting”

  1. 59Carmean Says:

    good day i came to youre blog, and I have read some awesome information on it.

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