Throughout my travels, I’ve come across many facilities, each with their different method of documentation. Some still use paper charts. Some use electronic medical records (EMRs). Some use a combination of paper charts and EMRs in a hybrid fashion.
Whatever the current state of the system in place, it seems that the trend is moving towards technology and EMRs. Reimbursement from insurance companies, safety, and the widespread access of an electronic record seem to be the rationales at the forefront of this shift. It’s something that we, as healthcare professionals, need to embrace because it’s not going away anytime soon.
One of the benefits of traveling is that you get to see what tools and processes other facilities use to handle similar issues. A huge tool in healthcare as mentioned earlier is the EMR, my favorite by far being Epic. To me, Epic seems to be the quickest to pick up and has the best flow to facilitate your workday. Epic is an EMR that is all built on the same database enabling seamless communication and functionality. It’s also pretty popular around the US which helps when moving around to different facilities because you’ll already be familiar with the system they’re using.
Although it is the same program, Epic allows for a great deal of customization based on the needs of the healthcare system which might take a little bit of time to adjust to when using a new facility’s version. However, it’s usually just a change in color schemes, how things are organized, and varying layouts. Moreover, the appearance may be different, but the overall functionality will remain consistent.
Probably my favorite feature in Epic that I use as an inpatient nurse is the patient list. It’s probably the first thing you learn when you go through training, but there’s tons of customization that you can do here that I don’t think many people take advantage of. Having just worked an Epic conversion (the health system was changing from their previous program to Epic), I’ve seen this many times over the last couple weeks.
The reasons why it’s so important to customize your lists and make them your own is because it saves time when navigating the chart, highlights all your important items given your patient population and role, and helps keep you organized when giving and receiving report.
Since I was just helping others adapt to the program and it’s fresh on my brain, I figured I’d share my preferences as an inpatient nurse on a telemetry unit for you to use as a template and tweak to your needs.
I tend to organize my list in a way that resembles an SBAR report style and then I’ll fill in my assessment in the blank areas. Remember that some of the headers may not be available at your facility based on the version they use or the options they’ve selected. Do your best to find them if they’re named something different or use a substitute for something similar if you like.
Also, remember that this is the list I use while working the floor as a staff nurse. You might find it useful to tweak some of the things listed below if you have a different role (e.g. charge nurse, break relief).
Top to bottom indicates columns left to right
(*) = Optional
- Unit (*) – shows unit, beneficial if you’re rounding on patients in multiple units
- Patient Name + Age + Sex OR Name/Age/Sex – either separate columns or as a combination
- Code Status – (e.g. full, DNR)
- Allergies – lists patient allergies
- Isolation – (e.g. contact, airborne, droplet)
- MRN – medical record number
- Chief Complaint (CC) – usually what patient says is their reason for coming to the hospital
- Problem – pulls in problems from problem list
- Diagnosis – reason for admission
- Med Due AND/OR Med Overdue – flag appears when a medication is due or overdue, respectively
- New Orders – flag appears when a new order has been written for a patient
- Treatment Team OR Attending – shows all those responsible for the care of the patient, may list phone numbers or pagers
- Diet – (e.g. NPO, clear liquids, regular)
- Insulin Meds (*) – nice for tracking the patients who need blood sugars at meal times
- Foley (*) – Foley catheter in place
- Telemetry (*) – requires cardiac monitoring
- Level of Care (*) – (e.g. med-surg, tele, ICU, step-down)
- Current Level of Function (CLOF) – beneficial for seeing how well your patients move (e.g. bed bound, ambulatory)
- Fall Risk – indicates patients at risk for falling (although everyone is a fall risk…)
- Braden Score – shows latest score, indicates patients at risk for skin breakdown
- MEWS (*) – last Modified Early Warning Score, shows risk for sepsis, beneficial to RRT nurses or general
- K (*) – shows most recent potassium level, beneficial on tele floors
- Mg (*) – shows most recent mag level, beneficial on tele floors
- Hgb (*) – shows most recent hemoglobin level, beneficial for just about any population
Here’s a little preview of what your final product might look like:
Inpatient Med/Surg Floor Nurse
As nurses, we’re flexible. Constantly adapting to the newest equipment, medical regimens, protocols, etc. Technology is no different. Be sure to go with the path of progress and avoid resisting change for the sake of “this is how we’ve always done it.” Allow it to facilitate your daily workflow so you can spend more time doing what you love: caring for others!