Computerized Medical Charting

Written by Norene Anderson
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Computerized medical charting has the ability to cut the time spent in charting down while increasing the time to spend doing actual patient care. Many hospitals have installed bedside computers in every room to facilitate entering patient information. Medication documentation can be done while at the bedside instead of waiting until all medications are handed out on the round and then sitting with a stack of charts to document.

It is much faster to point and click on the appropriate findings during an assessment of the patient than to write everything out by hand. The work of the nurses, lab technicians, respiratory therapists, and all other support personnel encountering the patient has been streamlined thanks to standardized forms for the various routine procedures and activities of the day.

See Computerized Medical Charting Possibilities

Computerized medical charting is also an advantage for physicians. All standing orders can be available for the physician to simply point and click on the items that pertain to a particular patient. Digitalized signatures make it a legal document the same as with nursing notes. The convenience of viewing all patient data with just a few clicks is much more time efficient than searching through the many pages of a paper chart for the one piece of data that is needed.

Most computerized medical charting software will accept input in a variety of ways. Some information is entered with the keyboard while other data may be entered by a pen, mouse, or voice recognition. The versatility makes it workable for just about any hospital setting. It is also a great option for physician's office records. Electronic data eliminates the need to have a storage room for old charts.


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