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hi guys, i wanted to ask if you guys can give me some input on the charting..I'm a new grad but been out of school since 2010, the hospital that i am working at right now is using EPIC for the charting. everything was pretty new to me. I'm struggling on my first and 2nd day of oreintation. tomorrow will be my 3rd day. i just wanted to ask you guys if you guys have any idea on the process of the charting. i've noticed that they don't use SOAP, fDAR..these SOAP, fDAR are the only 2 that i am familiar with during school days. to give you guys an idea here's the example given to me as a sample but not the actual. i've been trying to get this on my head hoping i can get a better understanding on how they formulate it. any infor will be a great help.. thanks
SUMMARY OF PATIENT PROGESS:
STATUS: No change Primary problem: New onset seizure, sinus tachycardia (they said the primary problem is the reason for the admission to the hospital)
Key findings related to primary problem: AOx3, no sob or cp, no seizure, hr 68, generalized weakness on the lower extremities, foley adequate output, seizure precaution maintained
Other key finding: c/o constipation dulculax supp. given as prn awaiting for result at this time.
We just switched to EPIC in January and it's okay. We do "pre birth visits/phone calls" where the patient comes in or calls in a few weeks before they are due and a nurse fills out most of their admission, so when they come in to be admitted we only have to fill in a few things. Of course some don't do it, or go into preterm labor and don't have a chance to do it, but the admission isn't all that bad. Make use of the tab on the side where you can see "Required Documentation". It will show you what you still need to chart and what was done.
I actually like the Labor charting. I feel like I chart a lot less, but the same information as before. We used to do a lot of double charting, and now it's more streamlined. No reason for me to chart delivery times or cervical checks I did not perform when the doctor is going to be charting them anyway.
Newborn charting in postpartum is a pain, because I end up going into a lot of different tabs and forgetting things (especially the RAPP score, why can't that just be in the assessment tab!). PP charting for mom is pretty easy, I have no complaints there.
Sorry I work night shift and have only done 1 or 2 discharges, so I don't know the ins and outs of it, but from what I recall it was pretty simple. Again, check the tab and click "Req Doc" and it will show if you are missing anything.