EPIC, documentation & time management advice - page 2
by Umrn1 24,216 Views | 17 Comments
I am looking for some EPIC documentation advice, tips, hints, etc. EPIC is new to our hospital. I feel we had the max training time allowed and overall I really like it, just unsure how best to approach it. I am mostly looking... Read More
- 0Nov 4, '10 by woohUsed to use Meditech, I like Epic better for most things.
Learn the first letters of things, learn to hit things with the ";" in between them. So for "Diminished; lower" I would type dim;low" and it's in. As was said above, don't double chart. If it's within defined limits, then you've already said their lungs are clear. If it's within defined limits, you've already said their pulses are 2+.
Customize everywhere you can to make it work best for you. Use your "wrenches" to make everything work as close to how YOU think as possible. Sure, someone else has x,y,z on their screen, but I want w,y,z. They think x is important, I think x is silly and want w instead. So that's what I have. I've got everything set up as close to how my brain works as possible.
Use the speedbar to your advantage. The flowsheets I use for everyone are there in the order I document on them. So it becomes habit to just click across as I chart. Then the ones I use most often are there next, like restraints, or PCA pumps, blood administration.
After a while, it becomes second nature to go through everything in order, just like you did on paper or whatever you used before. You can also make a little checklist for yourself, things you have to do, on paper for yourself. That way you don't keep going back making sure you did things. I still use that, my brain sheet has a checklist of vital sign times, reassessment times, IV, I&Os that I can cross off when I've charted them so that I don't wonder at the end of the day if I did them. I've now gotten to where it's so systematic for me that I don't need the checklist anymore, but I still like to keep it as my security blanket.
Good luck! I think once you get past the "everyone hates change" aspect of it, you'll learn to like it.
- 0Nov 5, '10 by Umrn1Yes Yes! I totally forgot about the wrenching tool! Thank you for reminding me of that. Hopefully this weekend will have a slow(er) day and I will work on my flowsheets and overall set up to customize more. I helps so much just to hear that everyone really does have their own way and I'm not doing it 'wrong'. I am definately double charting my initial assessment details and I've got to stop that.
Another question: Should I be adding in an RN progress note, similiar to the Drs and other diciplines? I have seen some nurses do this and I have to admit, I like having the note especially if its something out of the ordinary, but wondering if I should be doing it. Is it helpful or just annoying???
- 0Nov 5, '10 by Umrn1More questions... How many of you document 2 assessments one initial and another focused, resolve care plan problems, resolve teaching problems etc. on every patient every day? I am also looking for advice on adding/deleting care plan items and teaching items. Before, I really was awesome doing all this for each patient (fewer pts though). Now, I'm not. How bad do I suck???
- 0Jan 28, '11 by NoviceRN10We have computerized charting where I work (not EPIC) and to keep on top of time management I open up the pt's chart on my computer (we all have our own) outside the pt's room and start the admission form, leave it open and (but close/minimize computer screen) go to my quick introduction and head to toe. I go right back to my computer and fill in the form (which is only a 2-3 minute process), and then either run and get them whatever they just asked me for (pain meds, ice, etc.) or move onto the next pt. I always have my charting done within an hour and a half of starting my shift, barring any occurences that require paper charting. Admissions are only two more forms; history and plan of care, both only take another 5-10 minutes tops to complete. If I have time I chart education. If I didn't get it done as I go I think I'd forget or get lost in other tasks .
- 1Feb 27, '11 by DolceVitaNot everyone has their EPIC systems set up with a WDL/WNL option. Even if yours does you may or may not have noticed that you can type "cra" in a lung assessment field and "crackles" will come up.
Also, get away from using the mouse if you can. Initially you may think using the keyboard is slower to navigate with but it really is not. If you are using the "enter" key after entering data in a field switch to using the arrow down key to get to the next field you need to fill in.
I always wonder why some places don't have some kind of master class for EPIC users. Some do. If you can get a focused training session after you have used EPIC for a few weeks their trainers can help you with all sorts of tips and tricks.
- 0Feb 27, '11 by Tina, RNWe're going live with EPIC in a few weeks at my hospital, too. I've gone to 2 of the classes so far, and have 2 more to attend. I'm just afraid that I won't remember to document in each section necessary. When you have your forms/flowsheets to complete, you can make yourself a list or whatever. Most of them were right in the MAR binder to remind you to fill it out. But there are so many tabs and drop-downs with EPIC, it seems impossible to remember it all. I have a feeling I'll still be clinging to my "brain sheet" for a long time after we go live...