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.