EPIC, documentation & time management advice

Nurses General Nursing

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  • by Umrn1
    Specializes in Med - Surg.

You are reading page 2 of EPIC, documentation & time management advice

Umrn1

15 Posts

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???

anlittleRN

1 Post

How do you copy and paste rows in epic?

resumecpr

297 Posts

Specializes in ED, ICU, Education.
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

901 Posts

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 :).

Specializes in IMCU.

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

513 Posts

Specializes in Acute Care, CM, School Nursing.

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...

Kurian, RN

1 Post

Hi, I have some time issues with documenting in Flowsheets in Epic and was trying to copy and paste data from one column into another as you suggested, but the system doesn't allow me to do so. Maybe it is due to Epic update or some other reason I have no idea. Could you give me any updates on this issue, please? Thank you.

NICU Guy, BSN, RN

4,161 Posts

Specializes in NICU.

If you want to copy and paste an entire column, right click the time at the top of the column. It will give you an option to paste to the last column or another column. If you want to copy only one item, right click the box and you get the same two options (paste to last column or another column).

Rnmo21

2 Posts

Copying & Pasting is fast, yet can be dangerous. You have to be careful to go through ea line item & individualize. Notes made also copy. Word for word can be obvious & wrong in a case I know about. Several shift nurses over 48 hour period copied skin assessment notes, yet, pt acquired a DTI during this time. All nurses involved were liable and written up. It is safer to go line by line with your own assessment, comparing to previous for baselines. Hitting tab button, or clicking on the choices in upper corner are all fast options.

Regardless of the millions of tasks that are added to our jobs, it all boils down to the golden standard. If it is not documented, then it's not done! The Nurse will always be like the first to be blamed! CYA!!!

Buckeye.nurse

295 Posts

Specializes in Hematology-oncology.

I try to at least time stamp every time I am in my patients' rooms...whether it be an IV site assessment, positioning, or pain assessment. Then when I have a bit of time later, I go back and fill in the rest of what I did during that time. If your hospital has the frequent monitoring flowsheet, wrench it in. It will be your best friend. Hourly rounding, I/O, positioning, daily cares, IV assessment, neuro checks, and respiratory assessment are all on that flowsheet at my facility.

Learn the art of tab and click. I got to the point where I could tab through an assessment pretty quickly after a few years using EPIC.

Expectations for charting will vary from hospital to hospital, and even unit to unit. On my floor we do a full assessment at the beginning of the shift, and those of us working 12 hours chart a focused assessment in the afternoon. I usually add a quick note too. Best of luck!

Specializes in Float.

What are the steps in epic for admission? Thank you all so much

Home Health Columnist / Guide

NRSKarenRN, BSN, RN

10 Articles; 18,306 Posts

Specializes in Vents, Telemetry, Home Care, Home infusion.

This thread is 2 years old, posters haven't been active posting so may not get a response.

Each hospital's EPIC is customized to that health systems requirements. Best to discuss with your nurse educator and preceptor.

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