Psychiatric Mental Health Nursing Assessment and the Electronic Medical Record


I am in agreement that the electronic medical record is not always ideal for charting a patient assessment. It takes thought to actually write down notes whereas sometimes in computer documentation you can get away with pointing and clicking. There is not always the correct symptom or description to fit what you are wanting to say. Today I assisted with a patient on my unit (in for a dislocated hip) but was apparently withdrawing from something. There was nothing in the computer to describe what this patient was exhibiting. She was screaming that someone was murdering her family, the next minute she was in church having revival. I am interested in looking tomorrow at what the nurse charted. We are also on electronic documentation. I think it is worse for nursing. The doctors at least have to write a progress note. The physical therapy notes include a lot of annotations. Computerized charting may be quicker, but I am not convinced it gives an accurate picture.


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