Computer versus Paper charting for nurses Essay

Computer versus Paper charting for nurses - Essay Example With so many responsibilities and so much information to assimilate, it becomes even more essential to take care of the documentation of information as this is the only method to reduce errors. Charting information regarding medication, observations, patients' history, etc. has been an age old practice and is the responsibility of nurses. The purpose of the medical chart is to serve as both a medical and legal record of patient clinical status, care, history, and caregiver involvement. The detailed information contained in the chart is intended to provide the patient's clinical condition by detailing diagnoses, treatments, tests and response to treatment, as well as any other factors that may affect the clinical state of the patient. Hence, it is beyond doubt that documentation is one of the most important activities that needs to be accurate. This essay compares computer and paper charting methods and also discusses in detail the history of charting technology; reveal medication errors in computerized and non-computerized charting, illegibility of orders and double charting, and accuracy. In the 21st century, nursing informatics has become a part of the professional activities. Informatics has advanced the field of nursing by bridging the gap from nursing as an art to nursing as a science. The term medical chart is a general description of a set of information on a patient. It is important that the information in the chart be clear and to the point, so that those utilizing the record can easily access accurate information. In some cases, the medical chart can also assist in clinical problem solving by tracking the past history of the patient. For instance, the baseline information or status on admission, orders and treatments provided in response to specific problems, and patient responses can be easily retrieved from the medical chart. Another reason for the standard of clear documentation is the possibility of the legal use of the record. For example, these records are frequently investigated for insurance clams and when medical care is being referred to or questioned by the legal system, the chart contents are frequently cited in court. In the earlier days, all the documentation was prepared on paper. But today, most of these are fed into the computers directly and is stored in it. The disadvantages with the paper charting are as follows: it is a tedious process to write and store the records and it takes away a lot of space. Since nurses work in shifts, different nurses handle each record as a result different handwritings appear in single report. A single nurse handles several patients as a result there are high chances of medication errors with serious consequences. These factors are even more of a problem for those nurses who are working in intensive care units (ICU). With the increase in stress due to shortage of nurses, the working staff will be handling more patients and many times it is possible that errors occur in medication. Nursing Informatics is a broad ranging field that combines nursing skills with computer expertise. Nursing informatics is the modern technology that