5 tips to chart faster in Epic

Our MD Tech Tip article this week is methods to chart quicker in Epic. We’re not going to bore you with a number of dot phrases or macros for our PE or ROS. Everybody is aware of that. I educate our residents on methods to chart quicker 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 deal with data gaps I’ve seen in senior residents when studying methods to chart. Whereas a few of the following may seem like refined workflow adjustments, they’ll yield important effectivity positive aspects.

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 kinds really 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 parts. Severity, onset and period have straightforward buttons to populate on this template. That is nice as a result of it provides you the factors you want to your stage of service to be excessive (1-5). I can’t emphasize this manner sufficient. It’s a small factor, however makes your HPI a lot quicker over time. I first fill out the “Sickness” type, after which will leap into the Narrative field and can dictate a number of traces accordingly. Whole time utilizing this setup to finish your HPI is lower than a minute.

Dictate, dictate, dictate (actual time)

When you have the power to dictate, dictate. Actual time dictation is one of the best. Transcription just isn’t best. For my part, having to attend for a transcription service after which assessment it for accuracy hours later just isn’t 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 accessible. If you’re not conversant in actual time dictation, it’s the potential to make use of a dictation software program, comparable to Dragon dictation, together with the EHR. For my setup, actual time dragon dictation is constructed proper into epic, and we’ve got energy mics that permit 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 type of millennials who grew up on keyboards and was very pleased with my phrases per minute. Due to this, I assumed that I may at all times hold typing quicker than I may dictate. For a full yr that our hospital turned on dictation I refused to change over, feeling that I may sort quicker. Lastly, a fellow school member satisfied me to no less than simply give it a attempt to it was an entire life changer. I’m not exaggerating in any respect. I discovered myself having the ability to save about an hour per shift of charting, and actual time dictation has saved me a whole lot of hours of my life that I’d have in any other case spent typing. I used to be capable of attest residents charts and in addition do particular person affected person charts a lot quicker. Put up switching over to actual time dictation, I used to be capable of end charts far more simply on shift and have virtually each chart completed previous to the top of a shift. For those who’re a type of that hasn’t converted to actual time dictation, please do. For those who’re at a system that doesn’t have actual time dictation accessible, push for it. You’ll get assist out of your administration just by saying it would assist get charts completed quicker in order that insurance coverage can billed sooner. In case your hospital needs to do one thing about morale, that is a simple lever they’ll pull.

Reduce your dot phrases

Arrange your medical choice making(MDM) with a normal dot phrase. The extra normal you might 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. Hold it easy (not at all times potential with some sufferers, I get it).

My normal dot phrase for my MDM is the next:

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

ER supplier interpretation of Labs:
@[email protected]
@[email protected]

Differentials thought-about:

Key medicines administered within the ER: @[email protected]

Medical Choice Making:

Key discharge directions:

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

Use floating home windows

Many suppliers don’t learn about Epic’s floating home windows choice. After I educate this to my senior residents, many come again and inform me that is the characteristic that helps them probably the most. This characteristic solely works nicely when you may have a two monitor arrange. When enabled, floating home windows are a good way to optimize charting by permitting you to multitask and in addition mentioning an incomplete notice each time you’re in a affected person chart. To entry floating home windows, go to your notice author. On the “edit notice” 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 notice to indicate up on a separate monitor, permitting you to do extra chart assessment whilst you’re filling out your notice.

My favourite effectivity characteristic from that is that after it’s enabled, each time you open the sufferers chart, your notice pops up when you have not pended it or accomplished it. It’s a continuing reminder to complete your notice or replace it.

Ensure your whole “wrenches” are optimized!

Epic has tiny wrenches all through many of the screens you’re in. These wrenches are essential as a result of they mean you can customise each display 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 employ to customise the menus you need to seem in entrance of you. This can mean you can entry historic check outcomes higher, mean you can see important indicators higher, and far more. I can’t let you know what number of occasions I’ve discovered merely reconfiguring a residents wrenches permits them to save lots of a number of clicks on each affected person chart.

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

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

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