September 28, 2023


Healthy Always

5 tricks to chart sooner in Epic

6 min read

Our MD Tech Tip article this week is easy methods to chart sooner in Epic. We aren’t going to bore you with a number of dot phrases or macros for our PE or ROS. Everybody is aware of that. I train our residents on easy methods to chart sooner and be extra environment friendly on shift. By means of hours of lectures I’ve given them, I’ve tweaked my instruction accordingly primarily based on suggestions I’ve gotten with what works and what doesn’t. Whereas the lecture and directions I give are extra detailed and nuance, there are 5 key takeaways I needed to current that can make your subsequent medical day extra environment friendly. Specifically, I concentrate on information gaps I’ve seen in senior residents when studying easy methods to chart. Whereas a number of the following would possibly seem like delicate workflow modifications, they will yield vital effectivity features.

Sickness HPI type

Use the “Sickness” template in Epic. Many have no idea about this. When doing charts within the Emergency room or clinic setting, use the sickness tab to pre-populate your HPI. I’ve discovered that utilizing Epic’s customized HPI varieties truly take for much longer. Manner too many clicks and variations. So for that stomach ache affected person, think about using the “Sickness” HPI type as an alternative of “stomach ache”. The Sickness type has an empty clean for “location”, “high quality”, “context”, and different key elements. Severity, onset and length have straightforward buttons to populate on this template. That is nice as a result of it provides you the factors you want to your degree of service to be excessive (1-5). I can’t emphasize this kind sufficient. It’s a small factor, however makes your HPI a lot sooner over time. I first fill out the “Sickness” type, after which will leap into the Narrative field and can dictate a couple of strains accordingly. Complete time utilizing this setup to finish your HPI is lower than a minute.

Dictate, dictate, dictate (actual time)

When you’ve got the power to dictate, dictate. Actual time dictation is the most effective. Transcription will not be superb. In my view, having to attend for a transcription service after which evaluation it for accuracy hours later will not be environment friendly. Dragon actual time dictation has been a life changer. I’m solely annoyed that I didn’t use it sooner when it was obtainable. In case you are not acquainted with actual time dictation, it’s the skill to make use of a dictation software program, corresponding to Dragon dictation, at the side of the EHR. For my setup, actual time dragon dictation is constructed proper into epic, and we’ve energy mics that enable us to dictate on the press of a button proper into the chart. You’ll be able to even put in orders with the assistance of dictation.

I’m a kind of millennials who grew up on keyboards and was very happy with my phrases per minute. Due to this, I assumed that I may at all times preserve typing sooner than I may dictate. For a full yr that our hospital turned on dictation I refused to change over, feeling that I may sort sooner. Lastly, a fellow school member satisfied me to a minimum of simply give it a try to it was a whole life changer. I’m not exaggerating in any respect. I discovered myself with the ability to save about an hour per shift of charting, and actual time dictation has saved me tons of of hours of my life that I might have in any other case spent typing. I used to be in a position to attest residents charts and in addition do particular person affected person charts a lot sooner. Submit switching over to actual time dictation, I used to be in a position to end charts far more simply on shift and have nearly each chart completed previous to the top of a shift. If you happen to’re a kind of that hasn’t converted to actual time dictation, please do. If you happen to’re at a system that doesn’t have actual time dictation obtainable, push for it. You’re going to get assist out of your administration just by saying it should assist get charts completed sooner in order that insurance coverage can billed sooner. In case your hospital desires to do one thing about morale, that is a simple lever they will pull.

Reduce your dot phrases

Manage your medical choice making(MDM) with a basic dot phrase. The extra basic you could be the higher. I’ve seen suppliers with greater than 20 dot phrases for customized MDMs. I’m unclear how that helps with effectivity. The extra customization you’re doing together with your chart, the extra time and complexity you’re including. Maintain it easy (not at all times attainable with some sufferers, I get it).

My basic dot phrase for my MDM is the next:

ER supplier interpretation of Imaging / Radiology:
ER supplier interpretation of EKG:

ER supplier interpretation of Labs:

Differentials thought-about:

Key medicines administered within the ER: @EDMEDS@

Medical Resolution Making:

Key discharge directions:

Clearly, manage your basic dot phrase to your medical choice making or evaluation and plan accordingly. No matter you resolve, simply be sure you are conserving it basic. It’s a lot simpler to go and delete sure components of your basic dot phrase than creating a number of variations. Once more, scale back muddle and complexity.

Use floating home windows

Many suppliers don’t learn about Epic’s floating home windows possibility. After I train this to my senior residents, many come again and inform me that is the function that helps them probably the most. This function solely works effectively when you will have a two monitor arrange. When enabled, floating home windows are an effective way to optimize charting by permitting you to multitask and in addition citing an incomplete observe each time you’re in a affected person chart. To entry floating home windows, go to your observe author. On the “edit observe” tab that exhibits up, you’ll see a tiny downward pointing arrow, click on this and also you’ll see the choice for “transfer to floating window”. This permits your observe to indicate up on a separate monitor, permitting you to do extra chart evaluation when you’re filling out your observe.

My favourite effectivity function from that is that when it’s enabled, each time you open the sufferers chart, your observe pops up in case you have not pended it or accomplished it. It’s a relentless reminder to complete your observe or replace it.

Be certain your whole “wrenches” are optimized!

Epic has tiny wrenches all through many of the screens you’re in. These wrenches are crucial as a result of they help you customise each display screen and the way information is offered to you. Don’t use the default setup! It’s worthwhile to spend 20 to half-hour on the primary screens you utilize to customise the menus you need to seem in entrance of you. This can help you entry historic take a look at outcomes higher, help you see important indicators higher, and far more. I can’t let you know what number of instances I’ve discovered merely reconfiguring a residents wrenches permits them to save lots of a couple of clicks on each affected person chart.

Two final items of recommendation. Solely chart what you do. Please be cautious of how you utilize macros and ensure your charts are correct. Lastly, chart in actual time as a lot as you possibly can. Even when it’s simply filling out the HPI, ROS, and the bodily examination. You don’t need to finish your medical day or evening with an inbox of charts which are clean!

Do you will have any extra ideas you’d like me so as to add to this? Message me on twitter (@iltifatMD) and I’ll add them to this listing!

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