Patients come first, charting comes later. So how can a nurse be expected to chart in "real-time"? It is recommended that documentation takes place in the actual time of the event, or shortly following, which is understandable. Some experts even argue the point that not following real time documentation means we're not using the technological advances of EHR to it's full potential, or, having information promptly available to all healthcare providers involved in the care immediately.
But, is it realistic to implement, and require nurses to chart in real time, perform tasks, and clock out on time? Healthcare facilities are spending a lot of money improving their EHRs, while trying to cut overtime, but how does it all sums up once you add the human factor?
As a nurse, one of the major reasons I love what I do, is the fact that I get to engage, converse, learn from and treat a person, and not let a computer screen overpower my ability to care for and interact with my patients on a personal level, therapeutic touch is getting lost in our virtual health care world.
My personal opinion is that computer charting, or paper charting for that matter, is a tool to improve my work, but it does not dictate how I care for my patients. Even though my superiors may argue otherwise, I believe that patient will always come first, if I cannot chart everything within my 12 hours, I will stay a bit later, but I will end my shift knowing my patients were well cared for.
A recent study regarding why nurses aren't able to keep up with real time charting states that majority of nurses cite patient load as the major factor. Charting will always take the backseat in my daily routine, like it or not. The same study, cited in a Medscape article states that if the issue with real time charting is high patient load and low staffing ratio, it would make sense that hospitals focus on reducing the workload, but please tell me if that is happening where you work?
I became a nurse to treat and care for human beings, a computer is a tool necessary nowadays to help me and those involved in this patient's care to communicate with one another, allowing for less mistakes and miscommunication, but the computer screen does not mirror the person I am trying to help.
The Dude Nurse
Klaus Campos, BSN-RN