Assessments and Point of Care Charting

Charting patient assessments is often a time consuming task, but vital to the care of the patient and record keeping. Nursing often jot notes down on a piece of paper, to only later record them into the computer system. Much may be lost in the translation. In addition, actions may be taken on the charting that in currently in the computer, though it may not always be the most current reflection of the patent’s status. Point of care systems have become paramount for charting in acute care settings, especially on critical care units. They often interface with medical devices to collect data automatically. These systems are often flowsheet orientated and provide graphing and trending capabilities. Optimally these systems create less redundancy, offer quick responses and interface with other clinical operations such as the laboratory and pharmacy departments. The computer availability is also an important consideration. Central computers have not always enhanced charting as they may take nurse from the bedside. Point of care charting should be convenient points of access to the system. Computers on Wheels (COWS) are found in many organizations. The portable, efficient system allows the nurse to chart in the patients room when appropriate. Bedside systems at the point of care focus on quickly capturing information that a nurse may otherwise jot down on their notes. Computer location should be given thoughtful consideration before investments are made in addition to the device’s speed and ease of use.

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