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EPIC, documentation & time management advice

Posted

Specializes in Med - Surg.

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 for the best possible time management advice. I've found that if I document assessments in the patient rooms as supposed to, I become too distracted by patient or other person talking to me or it just simply takes too long in general. Here's what I'm doing now. I begin my 7am shift by checking on each patient and doing initial assessment. I then start by passing meds, and then doing dressing changes and fulfilling other orders. I find myself not documenting until around 2-4 pm when seems to be the most common time I'm "caught up" and am doing Is and Os. I take notes and just go back and enter what I did in the correct time slot. This also is time consuming and if anything at all goes wacky, I'm still trying to catch up way after my shift is supposed to end. I also find that I am not getting to resolve care plan problems each shift; mainly due to simply forgetting to click on it. I charted very well and often on paper and I just am scared of not doing enough on this system.

I've only done one direct admission assessment and all the documentation is done in the room at that time of course. I must get faster with this also.

If anyone has developed a "system" that works well for them and timing and reducing errors, etc. please share advice. Plus, I am a new grad from May 2010 and recently off orientation so time management and getting a "routine" down is still not something I have mastered yet. :confused:

felineRN

Specializes in Emergency Nursing. Has 2 years experience.

My advice is dependent on whether your system is set up the same way in your facility:

For head to toe, I generally hover over what the last shift documented (in doc flowsheets) and for each pertinent category (if nothing has changed or I concur with the assessment) I simply highlight and copy the column to a new time (my assessment time). I may add or delete details of the assessment depending on what I assessed. *Copying and pasting can save you a lot of time, but be careful what you copy. *

Don't double document. (Unless required) If you chart lung sounds are WDL, why chart that lungs are clear, breathing unlabored, etc...

For Admissions: There are only a few areas that require you to be directly with the pt. I always do my assessment, I ask about belongings, health history, allergies, home meds, and im out the door. The rest of the care plan crap, xferring pt from ED or wherever, and pt education can be done outside the room in a jiffy.

Resolving goals or problems in care plans: If you have the option "Multiple" under pt education...this button is your friend. You can document for multiple problems/goals without having to click each one.

Hope this helps! I find that having a set routine never helped me because people are always in my business and pulling me away from things. Find a cubby hole or computer away from the hordes of people and get your documentation done when you can! Good luck!

Umrn1

Specializes in Med - Surg.

Thank you so much! This will help me. I love the hiding part. That is the one thing I have figured out. If there is an empty patient room, You can find me there trying to get documenting done, lol.

msjellybean

Specializes in Emergency. Has 4 years experience.

My advice is dependent on whether your system is set up the same way in your facility:

For head to toe, I generally hover over what the last shift documented (in doc flowsheets) and for each pertinent category (if nothing has changed or I concur with the assessment) I simply highlight and copy the column to a new time (my assessment time). I may add or delete details of the assessment depending on what I assessed. *Copying and pasting can save you a lot of time, but be careful what you copy. *

Don't double document. (Unless required) If you chart lung sounds are WDL, why chart that lungs are clear, breathing unlabored, etc...

For Admissions: There are only a few areas that require you to be directly with the pt. I always do my assessment, I ask about belongings, health history, allergies, home meds, and im out the door. The rest of the care plan crap, xferring pt from ED or wherever, and pt education can be done outside the room in a jiffy.

Resolving goals or problems in care plans: If you have the option "Multiple" under pt education...this button is your friend. You can document for multiple problems/goals without having to click each one.

Hope this helps! I find that having a set routine never helped me because people are always in my business and pulling me away from things. Find a cubby hole or computer away from the hordes of people and get your documentation done when you can! Good luck!

Agree! We use EPIC and one of the more seasoned nurses I work with always complains that her assessments take her forever. Well when I follow after her and see that she's charting respiratory as WDLw/ clear lungs sounds, peri neuro as WDL with +2 pedal & radial pulses, regular apical & radial pulses, etc. and so on, it's no wonder. WDL and move on!

sameasalways, ASN, RN

Specializes in Med/Surg. Has 11 years experience.

Wow I FEEL stupid but what is "WDL"? We use Medi-tech and I wonder how similar it is to EPIC documentation systems?

Reno1978, BSN, RN

Specializes in SRNA. Has 6 years experience.

WDL = Within Defined Limits. So basically, in EPIC, if the patient's respiratory system is normal - the patient is on room air, lung sounds are clear, SaO2 > 92%, you can simply call the respiratory system "WDL" instead of going into the subcategories and explicitly listing normal assessment results.

We use McKesson, but are switching to EPIC. In McKesson, we used WNL (Within Normal Limits).

Up2nogood RN, RN

Specializes in pulm/cardiology pcu, surgical onc.

WDL = Within Defined Limits. So basically, in EPIC, if the patient's respiratory system is normal - the patient is on room air, lung sounds are clear, SaO2 > 92%, you can simply call the respiratory system "WDL" instead of going into the subcategories and explicitly listing normal assessment results.

We use McKesson, but are switching to EPIC. In McKesson, we used WNL (Within Normal Limits).

We also use McKesson and are switching to Epic within the next few years. I'm glad it sounds similar with the copy/paste feature as I find this saves a tremendous amount of time. But I always check what I'm charting as some people will chart (or omit) odd things for respiratory for like 5 days without changing it and it makes me wonder.

I always chart in the rooms right off the bat. Go in meet my pts, assess, chat and chart then off to the next.

nurse2033, MSN, RN

Specializes in ER, ICU.

My EPIC uses letter key recognition, for example in the heart rhythm box, if you type in NS then the enter key it will recognize normal sinus rhythm. This saves me the time of accessing the drop down menu and clicking on the selection. Once you learn these you can halve the time it takes to record an assessment. This is especially helpful in documenting restraints as there is rarely any variation in the documentation and you can't copy that section.

Be sure to use the "Details" box. Click click click away. Right-click to immediately jump to the next box down. I usually do my initial assessment/med pass then chart whenever I have the time throughout the day in between other tasks. I never really chart in the room because, like you said, it's too distracting. When we first switched to Epic, I made a little checklist of all the flowsheets/careplans/education I needed to chart on so that I made sure I wasn't missing anything.

sameasalways, ASN, RN

Specializes in Med/Surg. Has 11 years experience.

oh okay...thanks (WDL/WNL..I had only said WNL before). The Meditech system doesn't have a box to check for WNL/WDL...but you can click "recal" and every box will be checked that the nurse before you checked. The problem is that the nurse before you probbly hit recall too and some of the stuff is completely inaccurate. So if your not careful it ends up being wrong. Its terribly redundant..but it is all I know. I will be moving soon and wonder what type of documentation system the new place will have..(wherever I end up working).

Used 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. :)

Umrn1

Specializes in Med - Surg.

Yes 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???

Umrn1

Specializes in Med - Surg.

More 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???

How do you copy and paste rows in epic?

resumecpr

Specializes in ED, ICU, Education. Has 7 years experience.

How do you copy and paste rows in epic?

Left click on the time at the top of the column to highlight, then right click and choose where to paste! I love that feature!

NoviceRN10

Has 5 years experience.

We 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 :).

DolceVita, BSN, RN

Specializes in IMCU. Has 9 years experience.

Not 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.

Tina, RN

Specializes in Acute Care, CM, School Nursing. Has 20 years experience.

We'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...