Two years ago my hospital transitioned to electronic nurse charting. Adapting this new form of documentation caused a rumble amongst much of the staff. It seems there is always a natural fear that arises when something so new in form is implemented. At that time I had only been a nurse for a little over a year, so I was open to just about anything as I was not too set in my ways. I continue to hear the occasional comment reflecting back to the good ol’ days when charting involved nothing more than a pen and paper. Last week our computer system was out of service for three hours for upgrades and as I was charting, once again on paper, I began to contrast and compare the two different styles of documentation in my mind.
Electronic charting has many benefits. It’s legible, finite, organized, and consistent. For example, intake and output are entered and it automatically gives the nurses and doctors a net positive or negative daily fluid balance. With paper charting we had to painstakingly calculate intake and output hourly, which is basic math, but still remains time consuming. Patients’ lab values are automatically uploaded to their e-chart which also saves time. Vital signs automatically flow from the bedside monitor to the e-chart and simply need confirmation to be permanent. No longer are the days of placing triangles and dots for graphical depiction of vital signs.
There are some negatives to electronic charting. As stated above, down time for upgrades is always an annoyance. It causes inconsistencies in the patent record and is a hurdle for newer staff that never used our paper flowsheets. Some aspects are actually more time consuming than that of paper charting. Lags in servers and computer glitches often time cause sluggish operating systems. And of course there are always times when you have almost finished charting a long, detailed note, when the whole system crashes!
Grievances aside, I guess at the end of the day we all know that patient safety is the most important concern. With that said, I must admit that electronic charting is much safer than that of paper, therefore it wins my vote. As stated earlier, there is little room for misinterpretation. There is consistency among all staff, and patient records can be accessed by physicians anywhere in the hospital. Perhaps we are in the initial stages of developing a universal system that can be accessed by all institutions across the country. Wouldn’t that be nice!
Tags: Health Care Informatics Electronic Medical Record, Healthcare Informatics, Healthcare Informatics Resources
Healthcare Informatics Resources 
Leave a Reply