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Electronic charting: Adapting to emerging technologies

Nurse Leader Weekly, February 26, 2007

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Technological advances will continue to affect the way we deliver and document care. It is impossible to anticipate which specific electronic or "bedside" charting systems you will be exposed to in your career. However, regardless of the systems, hardware, or software that you may use, here are some general tips to help you and your staff adapt to these emerging technologies:

• Familiarize yourself thoroughly with the features, functions, and limitations of a given technological tool. What works? How does it work? What does not work?
• Take it easy and allow yourself time and practice to learn the new technology. If instituted by your employer, demand ample orientation training with it and think of it as learning to master a new IV pump or any other piece of clinical equipment. Remember that the key to reaching familiarity with a particular tool is plenty of practice time with it.
• Your "support person," or individual versed in the particular piece of hardware or software you are using, may be an in-house expert or a factory representative. Have your support person's contact information handy and do not be afraid to get in touch with him or her should problems arise.
• The broad implementation of a technology such as electronic charting is going to be a new experience for your institution, as well as the technology provider. Your opinion and usage matter. Be prepared for glitches and take a collaborative approach to the whole project.
• Know the "back-up plan." What if the system goes down? Chances are, it will. So be familiar with, or have a plan for, an alternative method. Be prepared to switch if you have to.
• Last, but not least, remember that new technologies should not replace the principles and goals of proper charting. For example, if a new computerized ordering system outputs a set of orders, it is still the nurse's duty to ensure that such orders are clinically appropriate for the patient. Technology is not a substitute for nursing judgment; rather, technological advances should represent new tools and avenues to enhance your practice.

One of the most exciting aspects of being a nurse is the need to stay current. Although changes are sometimes disruptive, try to approach the adaptation of new technologies with an open and welcoming frame of mind. The right attitude will go a long way!

Editor's note: This excerpt was adapted from HCPro's book "Charting: Documentation & Medical Terminology Clinical Nursing Reference, Second Edition," which is part of HCPro's Quick-E! series. Click here for more information.

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