*Original post released on 11/14/2022
We often take our charting and E-MAR systems for granted too much. Imagine walking onto your unit for your shift only to find that the systems are completely down. You have no access to the patient’s labs, medication list, orders, progress notes, health and physical notes, recent assessment data, and nursing notes. Believe it or not, last week, this exact situation happened to me while on an ICU contract. This may seem like an insurmountable feat, however the most important thing is to do your best to not let it get you flustered or worked up. Maintaining your composure will go a long way in helping the shift go well for you and for your patients. In this article, we’ll discuss some of the insights I’ve come to realize since that outage and want to share with you. It is my hope that these shared insights will help arm you with advice for success should this ever occur to you. Without further ado, let’s dive in!
Gather up copies of the necessary documents before you even get to your patient assignment. Your facility will likely already have them at the ready, unless, of course, the outage occurs mid shift. Be sure you chart as soon as possible, in as close to real-time as possible, and don’t save your charting until the end of your shift. Doing so can affect the accuracy of your charting and the level of detail you include that may protect your license in the future should any action be taken against you. While charting, if the patient has a body system with abnormal data, chart that first. Again, the reasoning behind this correlates with the accuracy and level of detail within your charting. To make things easier on yourself, utilize approved shorthand for time-saving. Be sure to review and follow your facility’s approved shorthand while charting. Be legible and concise, yet thorough to the necessary extent.
Avoid charting the same information more than once, because doing so increases the likelihood of inconsistencies and/or inaccurate information. Consistency is key for every entry that you chart for the same patient. To help with this, have paper on your person at all time to be able to jot down notes, important times for events, orders, labs, results, MD communications, etc. Take notes on your patient’s status every 2 to 3 hours because paper charting will likely not be as extensive as the computer system. Notes should touch on subjects like their current status, any change in status, vitals, meds/drips currently infusing, interventions completed, MDs called, new orders received, etc. If there’s not a dedicated place to chart an intervention or assessment, make a nursing note for the information. This helps you cover yourself in the event of future litigation.
You can expect different sheets to chart aspects such as:
- Medication administration or withholding of medications
- Cosigners for insulin, narcotics, wastes, high alert drugs, and IV drip medications
- Titrations of IV drip medications
- New orders received (anticipate a new sheet for each prescribing provider)
- Vitals and I&Os
- Assessment data (the frequency will likely depend on the unit you’re assigned to)
- Lab requests
Keep your providers in the loop with pertinent labs, test results, etc. and make sure that when they are present at the bedside, they sign their specific order sheet as applicable. Make a copy of chart sheets like requests for lab and pharmacy. Send the copy to the appropriate department so they are notified, and then call them as a courtesy notification as well (and also to ensure that the order gets completed in a timely manner).
To guide your nursing care throughout the shift, look through the patient’s chart for their most recent labs, test results, and medication list. If you don’t see any recent records, notify the appropriate department and request a copy of the most recent information. If you’re in ICU, you should have lab results from the day of to guide your nursing care. For the med list and their times, attempt to access this information via your medication dispensing system (Ex: Pyxis). In my situation, I utilized the pyxis to review the times for each med that was due on my shift. You should also contact pharmacy to see if there is a way they can provide you with a copy of this information. For one of my patients, they had an IV medication due every 8 hours. If I hadn’t cared for her the night prior, I would not have realized this without contacting pharmacy.
At the end of your shift, make sure you have the patient’s chart available to review with the oncoming nurse if the computer issue(s) have yet to be resolved. This will ensure that you review their vitals trends, recent labs, test results, med administration record, nursing notes, and new orders received. This is especially important should you have any pending, incomplete items that will need to be completed by the oncoming nurse. Chart a note about who you gave report to, their title, and the date and time to signify the transfer of care responsibility.
I hope you never experience a situation like this, as it is a situation with the potential for mistakes to be made which can have adverse effects on your patient and to your license. Hopefully these few tips and pieces of advice will guide you in the event that it does occur. Until next time, happy studying!