Digital/computerized charting...

Boog'sCRRN246, RN · May 14, 2011

I'm not familiar with EPIC, but most of the other computerized charting systems I've used have had the usual boxes to check, but also included areas where free text could be entered if the nurse felt the need to provide extra, or more descriptive, info.

I had an instructor who absolutely hated 'WNL'. She described it as 'Was Never Looked at'...I'm still undecided on how I feel about it. To me, leaving a portion of an assessment blank looks worse than saying everything is normal. I guess I would be kind of stuck also, if there was no area to enter free text to further describe 'WNL'.

manchmal · May 14, 2011

This computer system has what seems like endless things you COULD assess -- most floors filter out their unit's preferred assessment data. Like an ortho floor would obviously want a full movement assessment, where a general med surg floor might not need that every shift. Or a one day post-op patient has a "flowsheet" of required assessments and you would add to that anything the physician asks for as standard.

You can chart additional text, but it's messy. This system has a 30 or so character limit in the field where you select descriptor words ("moist" or "clear" or "hypoactive") so you could add a BRIEF note. You could also add a nurse's note entry, but those are not associated with or "next to" the assessment data, and are usually used for charting events.

I wouldn't leave a pertinent assessment blank, but where to draw the line with infinite amounts of data? In the older paper charts, we had an assessment sheet of everything that facility wanted checked. But computers can include so so many possible assessments...

helicoptergal, BSN, RN · May 14, 2011

We are switching to a new system in July. I have worked with EPIC and was not pleased. With our new system we are encouraged to not right WNL as it is to ambiguous and cannot be specialized to fit pts with special needs. I live in the pediatric world so it will be interesting changing to computerized charting. Just have to keep the big picture in mind and know it will get better. Good Luck!!

JustaGypsy · May 15, 2011

You should be able to say "no" and be more specific in your assessment when appropriate

NicuGal, MSN, RN · May 15, 2011

We use EPIC and it depends on how it is built. We have WNL with descriptors, but if anything is not within WNL then we put X and there is a drop down box to pick things from or OTHER and then you free text.

I will say this, lawyers who are defense attorneys for the hospitals hate this charting, it is too easy to get into a rut and chart the same thing or not chart at all. Plaintiff lawyers love it because it leaves all kinds of openings for them to embellish on.

When in doubt, write a narrative in the progess notes or in your careplan.

manchmal · May 15, 2011

It's actually the legal side I'm concerned about so thanks for bringing that up! I think it's easy to think checkboxes eliminate confusion, but humans are complex entities with issues that need more than a yes or no. Thanks for everyone's input! I need to

do what feel right to me, bottom line, and that's being as descriptive as I can be with the time I have to chart in.

msjellybean · May 15, 2011

My hospital uses EPIC and I love it (of course, it's the only charting method I've ever used, so I do have that bias).

I wanted to chime in with a comment from the legal angle, since several other people have already. I follow so many nurses that will chart WDL on the systems and then have something grossly abnormal. GU is WDL and they have a foley. Peripheral neurovascular is WDL and they've got +4 edema in their BLE. When I see this, all I can think of is that if something went terribly wrong and this chart ended up in the hands of lawyers for a malpractice case; their charting would be torn to shreds.

From what I've been told by our educators, the WDL label is all we need if something is truly WDL (and each system has a comprehensive list of what is considered to be WDL). And they actually do not want us to chart beyond that if it's WDL, for legal purposes. Of course though, people still do it.

hannahmaepunk · May 15, 2011

If you haven't done it, leave it blank. Don't encode WNL. Simple.nursing conscience. If your clinical instructor begs to disagree, that's not your problem. If he/she forces you to do something or write something that you didn't really do, report report report!

nfdfiremedic, BSN, RN · May 15, 2011

I have used EPIC for years and I've always been happy with it. For situations like you described (i.e. patient's sat is high 90's while awake, high 80's while asleep) I just document whatever the sat is at the time I record vitals and in my note I wrote "sats dip to high 80's while asleep but quickly rise to high 90's upon waking."

EPIC can be configured a million different ways. Most of your assessment is done by clicking little boxes on a flowsheet but, unless your institution has eliminated the option (and I can't imagine they would) you can still write a note saying whatever you want above and beyond all the little boxes you clicked. I'd encourage you to just do this to "fill in the gaps" and make sure the details are all included.

Also, with regard to charting things like vision/hearing, etc... If those things have nothing at all to do with the reason the patient was admitted and they have not expressed to me that they have any issue in those departments, I don't consider it wrong to mark "WNL" for them. If the patient came in with cellulitis of the leg or something and they didn't present with any obvious visual or hearing deficits while you're in the room with them that's not inappropriate. You don't need to do a focused, rigorous exam on these systems top determine that they are WNL. This is part of the "overall picture" that you get of the patient when you perform your assessment. If they're in for something totally unrelated and they don't present with any obvious deficits or report any, it's ok to say WNL.

Think of it like the check engine light in your car. If the check engine light comes on, the car is saying to you "Hey, I have a problem with my engine!" and you know something is wrong. If the light is not on, you don't need to pop the hood and do a full mechanical inspection every day to ensure that there is nothing wrong with the engine do you? You would just be comfortable in the knowledge that the engine seems fine to you as you drive down the road and if something was wrong with it, it would tell you by turning on the check engine light.

manchmal · May 15, 2011

Hmm. Is ours the only Epic that caps notes at 30ish characters? After I pick an adjective from the drop down window, or type in a value like o2 sats, I can click to type a teeny note. It is literally 30 characters, so 6 or so words. Then it gets cut off. Which leads to horrendous abbreviations that are hard to read. I can type longer notes but they aren't under the assessment flowsheets.

I do get your point about the car engine light. I think I'd still think it would feel weird to declare (legally) that my car has no defects if I hadn't really checked it out. I wish it said something other than "WNL" or "WDL." I wish I could write "no apparent abnormalities" or "no verbalized problems." That would feel more accurate to me. In Epic, when you click to see what WNL means for that system, you're agreeing to a whole lotta normal!

Thanks for Epic tips, too! Different units seem to vary in how they document. Some use WNL and no other descriptors if WNL is declared. Others use WNL plus they add in all the "normal" descriptors. And some put an X if something is out of normal limits, and only use the descriptors to describe what's abnormal.

nfdfiremedic, BSN, RN · May 15, 2011

I think you are talking about the individual notes for each parameter, correct? The little white piece of paper icon you click on that lets you free-text in around 30 characters? We have those too, but that wasn't actually what I meant. I use those little note fields for things like writing "manual" as a comment for a BP I entered, or "Room air" as a comment for a sat or something (we tend to do manual BP's and room air sats for our first set of vitals and then use the auto cuff, etc. after that.)

I'm talking about the actual "Notes" tab. The one docs use to write progress notes. We can click on that and select note type (in my case I use "ED Notes" but there is also a "Nuring Notes" option.) There's no limit on the size of those notes, and you can write a novel in there if you feel like it.

Also, in rereading my first post, I feel I might not have adequately described what I meant with the check engine light analogy. At the start of your shift you go in and greet the patient, perform your assessment, give meds, and identify any other needs they may have, right? Essentially, you have screened them for visual or hearing changes, etc during all of that. You don't actually need to go in there with a tuning fork and an eye chart to determine that they have no apparent deficits with hearing or vision. Perhaps that's a phrase that might make you more comfortable? "No apparent deficits?" I use that a lot. You could just click WNL and type that in the comment box for the field. It imples that you didn't note anything out of the ordinary when conducting your routine assessment of the patient.

Let me know if I can be of any more help with EPIC