computer charting help please

1092c

Forum Ride Along
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We have been using a computer charting system for some time and it has raised several questions. The biggest question and the one I would like input on is how to use the narrative. Our system uses a lot of drop down menus that cover ever thing but the kitchen sink. we have some guys that say you only need to put information in the narrative that is not covered in the drop downs (pert neg's, pert pos's etc.). This leads to a short narrative and all required information is printed in the chart. While others say you still need to write a full narrative because it's the only part of your chart they pull up in court. They say you need to write a "stand alone" narrative to cover your self. Our company all so doesn't have a policy on this matter at this time. what say you? thank you very much for your input.
 

Joe

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My theory is when you go to court its easier to recall information from your narrative because the e charts dont flow like your brain does. Some words may trigger memories. I always write a complete narrative from dispatch to handoff. You could write the minimum 10 characters and send it off but is that where you want to be when jesus comes?
 

Handsome Robb

Youngin'
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If they're going to subpoena you and your chart for court they will have the whole chart, not just bits and pieces of it.

My narratives are short. Subjective and Objective. A.P. is generated through drop downs and check boxes.

The only good way to charts the way that works for you and is thorough.
 

cruiseforever

Forum Asst. Chief
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When I first started using electronic charting I was wondering the same thing. I had a few of my forms printed out to see what they looked like on paper. After doing that I had a better understanding on what I wanted on my narrative. In our system the chart is sent to a fax machine in the ER and printed out for the hospital.
 
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1092c

Forum Ride Along
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It looks like it's about 50/50. Do your companies have policy on how you have to write your chart? thanks again
 

Akulahawk

EMT-P/ED RN
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I haven't done any EMS e-charting in years, though I've done some charting in an EMR system since. Out here, our hospitals use EPIC, and there are assessment flowsheets that cover nearly everything. This system also requires you to do charting by exception, and they do define what "within normal limits" is, so that anything that doesn't fit "WNL" must be charted on.

That being said, my "Nurse Assessment Note" covers the "S" parts of the charting, as there isn't a way to do flowsheets for that stuff. I also include "O" parts of the assessment that need some expanding upon because some of the drop-down's don't cover some details, or aren't detailed enough to paint a good picture of what's going on.

I don't write the "AP" part in the EMR as that's covered elsewhere. However, if I had to do EMS charting, I'd most definitely do some kind of "AP" narrative... if only to state what I thought the problem was, or which protocol(s) needed to be followed, and all care delivered after that would be noted in a treatment-response section of the chart.

However, as I said before, I haven't done e-charting in many years, but that doesn't mean I don't remember how!
 

NYMedic828

Forum Deputy Chief
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You need to see how your program finalizes the PCR.

For example the one we have, takes all your drop down options and formulates an organized report out of it. It also have a narrative section. I can choose to use one or a combination of both.

If I use both fully, it results in a redundant report.
 

phideux

Forum Captain
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I work both 911 and IFT. In the 911 job, the system we use has a spot for a full narrative, plus all the usual drop downs. In the IFT job, the system takes all the info from the drop downs, and generates the narrative from them, but we can add to it. I tend to overwrite my narratives. If, or when, one of your calls end up in court, it is always good to have more info than less.
 

Tigger

Dodges Pucks
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Though the majority of my narrative is covered by check boxes and whatnot, I still write a full narrative like I did when we had paper charts. It's not going to hurt anything, and even the most complex BLS call just doesn't take that wrong to write up. It can only help me later.
 

medictinysc

Forum Crew Member
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I follow the old adage I used when I had paper DHEC's If it's not written down it didnt happen. I write everything. I mean everything.
 

MSDeltaFlt

RRT/NRP
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I go into detail on all preset boxes on assessment and even on treatments. By the time I'm at the narrative, typing all that again would be redundant. Not only that it would be repetitive.
 
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