"Epic" charting

I'm not a nurse yet but our entire hospital system uses Epic charting...the only things on paper are the appropriate consents and the ppwork that goes to the state...

massbaby said:

Has anyone gone to paperless Epic charting in Labor and Del or Post Part?

We use it were I work (Mom/Baby & SCN). I'v been there 3 years and they were using it before I got there. Let me know if you have questions. I would be happy to help.

Yup. I like it for Postpartum and NICU, but hate it for L&D.

Yes, our facility uses it hospital-wide, including L&D/Mother/Baby. It's the only EMR I'm familiar with for L&D, so I have no complaints.

Thanks for your reply getting use to it but a lot of sreens and clicking Admissions to

to L andD seem to take forever 

Any tips would be appreciated Seems like with all the screens I just go back to a good ole nursing note!!!

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.

HI

thanks for your rply can you given me some advice about how you document your mother baby discharge instriuctions --it never seems complete or done of course i always do a note too

ty!

do you use Stork monitoring with epic?

may ia sk why do you hte it for L&D it is difficult!!

I am new to EPIC and would like to know how to locate a discharged patient. Please help.

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.