Fresh out of high school, I had no particular career in mind. Since I was always able to make a living working with my hands, I worked in factory maintenance and studied nights for my associates degree in Electro-Mechanical Technology. I enjoyed most the computer programing which by todays standards was archaic. Punching holes in strips of paper, or typing non-sensical grammar commands.
Life took me where it wanted and I found my true love, ER Nursing. As computers became more common, I’d use my spare time for things such as complex spreadsheets which would save managers many hours (as well as pencils, erasers, and grey hairs) making schedules.
I was enthusiastic when I first heard that we were looking at going to computerized information management (ie; charting). My enthusiasm was replaced by great disappointment when I was introduced to what some sofware engineer thought was how ER charting needed to be done. I’d expected a certain disconnect changing from paper to electronic charting. Paper charts are 3 dimensional. You can pick them up and look through them to find what you want, where you want to be or get an idea of how it’s laid out so that you could adapt.
Computers are harder to relate to because looking at a screen, it’s not always easy to tell how to navigate the chart, what other areas there are to navigate to, and getting a feel for the overall layout so that you can adapt, can be difficult. Each system came with it’s own agenda, too. One of the most common systems was nothing more than a book keeping system designed to capture charges through our “charting.” Each system had a different emphasis.
The software implementation was, in my opinion, terrible. After working with 3 different systems with wildly different designs, it was obvious that none allowed me to accurately paint a picture of my patients. My only comfort was that, were I to go to court, the documentation allowed by the particular system would make it even harder for attorneys to make conclusions and arguments with. The computers, in an effort to make things easier, had limited choices in many areas where a written description would be more accurate.
For example; urine output was described in cc’s with a limited number of color choices and no way to describe sediment or that urine was leaking around the Foley catheter. When documenting blood pressures, no longer could I indicate that the patient’s upper arm was too large for a thigh cuff, or that it tapered so much that no cuff would stay in place. In these cases I might reluctantly take a forearm blood pressure and pass along to the next shift my technique so that while the results might not be ideal, we could still see an accurate trend. I could never find an easy way to note these things so that months or years later I could explain them, or even be able to tell if information had been “disappeared” from a chart.
On that point, I’ve seen frequent instances with written records where pages disappeared when some problem with patient care arose. There was no way to prove how this happened but the charts always had obvious holes in them from missing pages or pages that had been partially copied over or changed. At least by proving the chart incomplete, if it hadn’t totally disappeared, there was reasonable doubt.
Computers may be more secure by having controlled access, but I could see that a nurse called on the carpet to look at a printout of the chart and explain some problem was at a great disadvantage in that he or she had no way to verify that he chart was complete and unaltered. Worse, when charting in one area automatically fills in information elsewhere in the computerized chart, there’s opportunity to make a false impression.
I still have high hopes for computer documentation, and I know of many nurses who have become quite happy with their systems. Current systems seem to all have steep learning curves and offer far more options than a single person can remember. Thus I see nurses all charting differently, according to the features they like to use. This causes information fragmentation and defeats the goal of having a patients information easily accesible, understandible, and in a specific format.
I’d like to design “a better mousetrap” of computerized charting and have a strong matrix for same in mind. It would probably end up being just an academic exercise because I could never compete with the resources of large companies.