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Reading charts

Posted

Specializes in New graduate RN.

I just got out of epic training and there is so much information! I have no idea where to start once I get on the floor.

When you start your shift and look at your patients chart, what are the top 5 things you look at first? 
 

Muchnof this is going to depend on how your facility has implemented Epic.  However, I will describe how I review the chart at the beginning of my shift. 

Starting in the summary tab I review the following:

  1. Overview: plan notes, treatment team sticky notes, LDAs (lines, drains, airways)
  2. Flowsheet: vitals, infusions, oxygen delivery, vent settings, I&O
  3. Meds Current:
  4. Active Orders: 

Next, I review the Results Review tab.  

I generally find everything I need in these two areas, but will occasionally view other sections based on what I got in report.

Best wishes.

Kastiara, ASN, RN

Specializes in Critical Care. Has 4 years experience.

It's going to depend on how Epic is set up at your facility, but I do the following:

1. Orders tab to review the patient's current orders.

2. I read over the doctor's notes to see what the plan is for the patient.

3. I go to the Chart Review tab and look at any imaging/procedures/tests the patient has had.

4. I go into my flowsheets to look at the patient's vitals to see what their trend has been. 

5. Finally, I go into the MAR to take a look at their current medications and to double check that I got an accurate report on what drips/fluids are currently running. 

Sour Lemon

Has 11 years experience.

3 hours ago, Newnurse23 said:

I just got out of epic training and there is so much information! I have no idea where to start once I get on the floor.

When you start your shift and look at your patients chart, what are the top 5 things you look at first? 
 

I go straight to the work list, which includes upcoming tasks and medication due for all patients. The most pertinent information has already been received in report (hopefully!).

At some point in the shift, I review diagnostic results, notes, and orders. Exactly when that happens depends on everything else going on around me.