Charting at Rex

After all of the posts last week about SOAP notes vs. PES statements, I was interested to see how things worked at Rex. I was not prepared for the chaotic system they use. They transitioned to writing PES statements almost a year ago, and they're getting ready to fully transition to using the NCP (ADIME). However, the electronic medical record (called RCare) is actually getting in the way. Each pt's RCare file is huge: there are ~15 tabs, each packed with info and sometimes even sub-categories. I had to take notes on how to find notes! It's pretty handy after you figure it out since things are arranged by date AND by topic, but it's only as good as the info put into it. Some docs (esp. visiting specialists) don't use RCare, so you still have to sift through the paper record to get everything. And the real problem is that there's no place for RD notes. The PES statement is usually entered in a text box at the very end, and no one looks at it except the RD's. There's definitely no space for the other aspects of ADIME. They're fighting with IT now to get their own tab and drop-down menus.

Another interesting issue at Rex: pts don't always get snacks or supplements, mainly due to the computer system. Protein supplements are especially important for pts with decubs (i.e. bed sores...took me a while to figure out that one), and even though the RD orders them, the nurses don't know to give them because they don't look in the section of RCare that we use. The order is also in the food service computer system, but nurses don't see that.

Like Laurie, I'm a little disappointed by the time RD's spend with pts. I'm shadowing the RD on the renal/pulmonary floors, and we spend ~20 min looking at the pt's chart (checking for wt change, alb levels, decubs, etc.), then maybe 5 min with the pt (or their family), and then another 10 min charting. Sitting in on pt rounds and just listening to the other RDs' stories has been really interesting though.

I had a "project day" today, which meant that I spent ~7 hours menially copying and formatting nutrition info for the cafeteria. Thank goodness the weekly RD meeting and a retirement party broke up the afternoon. I got to try Angelo's famous mac and cheese and the party...pretty good.

Oh, and I got called a "little girl" by a pt. I'm going to have to do something to look at little older when I start counseling pts.