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I know everything!

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by ApplePineApple ApplePineApple (New) New Nurse

My preceptor and I argued over charting in the ED. Basically, the culture here is instead of using click boxes you just write blank notes in epic for everything including your hourly rounding. Not a single running note but blank notes. As in patient sleeping for five hours? Make that five notes. Oh and add another one for the tray you ordered. So say when I want to look at a previous ER visit, I have ten nursing notes which is crap info to wad through to find out the patient flipped out and broke a computer (an example).

So today we didn’t see eye to eye to charting that the company specifically developed for this problem. Basically, to fix it company added Y value to epic to solve the problem. They did this at least 2019 if not earlier due to new standards. So anyway, he got mad and I asked him to come back so I could show him what I was talking about. He said, “I don’t need you to show me anything in epic.”


Well, later I watched him use the sedation narrator. Not sure who trained him but I have never seen someone butcher a sedation narrator as bad. One benefit is the one step meds. Well, not sure if he knows what that is. Every med push documented as a blank note. I get you have to use blank notes but uh, everything was a blank note besides the arrival and time out. Sure some things need to be blank notes if the company doesn’t populate them but we’re talking 15 pushes of a medication and each one a blank note. 99% sure he made more work for himself. Oh and not sure who audits the charts but other ERs I worked in they required some sort of sedation scale to ensure the patient wasn’t overly sedated and to help track return to baseline. Not a single one charted.

But hey, he knows epic!

edit: this hospital system has had epic for almost a decade. This nurse is also younger than me. They also are not allowed to use the trauma narrator for traumas like other hospitals in the system use because they missed things. I am guessing the blank notes have something to do it with it.

Edited by ApplePineApple