Suggestions to complete EPIC notes on time

[Resident0123x]

I am in my 1st year Residency. It has been 6 months since I am in the program, and I am still lagging compared to my peers in completing EPIC notes on time. My typical day consists of inpatient, outpatient and hospital rounds. I start tying notes at the end of the day and it extends into late hours.

Any tips such as copy & paste of older sections and typing in between patient hours. Are there any technical features of EPIC that can speed up my notes completion. Being new to the environment, I am not able to figure it out and schedule my time effectively. I am clearly missing something.
Thanks

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[Raryn]

I am in my 1st year Residency. It has been 6 months since I am in the program, and I am still lagging compared to my peers in completing EPIC notes on time. My typical day consists of inpatient, outpatient and hospital rounds. I start tying notes at the end of the day and it extends into late hours.

Any tips such as copy & paste of older sections and typing in between patient hours. Are there any technical features of EPIC that can speed up my notes completion. Being new to the environment, I am not able to figure it out and schedule my time effectively. I am clearly missing something.
Thanks

For the inpatient stuff, start typing your notes in the morning while you're doing your initial chart review.

Review something, paste it (or summarize it) into the note. Copy forward or copy/paste the assessment/plan from yesterday. If you have time, update it somewhat for today. Rinse and repeat for each patient. Your chart checks in the AM may take a bit longer than otherwise, but it's a fairly efficient system when you get it down pat.

Round->update the changes for the assessment and plan (if any)->sign notes. You should be able to finish most of them pretty quickly.

For outpatient, it gets a lot more annoying. If you know who you're seeing ahead of time (like your continuity clinic), you can do some of the same things with pending a note before you see the patient, but in the end, the only real tip is to type as much as possible while you're in the room with a patient. It's a hard skill to balance with actually having a good interaction with the pt, and something I still struggle with finishing in a timely fashion.

 

[NotAProgDirector]

I would ask your colleagues what they do. Each EPIC install is somewhat different, and seeing what systems they use might be helpful.

For inpatient notes, we usually copy the prior day's note and update. This is very controversial, so you should ask whether it's allowed. When done well, it saves lots of time and generates useful documentation. When done poorly, it creates a mess if incorrect / out of date notes.

If you're slow at typing, consider Dragon Dictate. Or practice and get faster.

 

[Resident0123x]

THank you very much Raryn and aProgDirecor

 

[caffeinemia]

I would ask your colleagues what they do. Each EPIC install is somewhat different, and seeing what systems they use might be helpful.

For inpatient notes, we usually copy the prior day's note and update. This is very controversial, so you should ask whether it's allowed. When done well, it saves lots of time and generates useful documentation. When done poorly, it creates a mess if incorrect / out of date notes.

If you're slow at typing, consider Dragon Dictate. Or practice and get faster.

The good old copy forward. Loved that thing. Lets you pound out 20 surgery progress notes in an hour.

 

[Resident0123x]

Thank you caffeinemia

 

[AdmiralChz]

Dot phrases. You can make entire progress notes out of them, specific for certain surgeries. Postop/postprocedure checks? Dot phrase. On our bariatric service, I had dot phrases for postop gastric sleeve, bypass, hernia, etc... - just F2 and fill in the ***. So easy, notes took me < 2-3 minutes if everything was straight forward.

 

[AdmiralChz]

Oh, and other residents can share their dot phrases with you - pick them up and make edits to them/make them your own.

 

[Resident0123x]

Thank you AdmiralChz. If you have some examples of Dot Phrases, could you please email them to [email protected]
Thanks again

 

[SLC]

Build macros for normal physical exam and typical ROS crap. Then you just have to click that little play button in the upper right corner of each and then change what's different.

Way quicker than clicking endlessly through both of those aspects of the notes.

 

[Resident0123x]

Thank you SLC. How do I build macros

 

[Dr.Acula99]

Be thankful you don't have paper progress notes like we do! Try and be as concise as possible, ive definitely learned to be after writing many paper notes per day this year.

 

[hello1234!]

I second the building macros for the ROS and PE section. I have different marcos for UTI, URI, complete physical, basic physical etc.

 

[Resident0123x]

Thank you hello1234!. How do I build the macros? Are they available in some form of templates or formats. Would it be possible for you to email those templates and smart phrases to my email id at [email protected]

 

[LUCPM]

The best person to talk to is one of the seniors in your programs. They can help you set up dot phrases, macros, etc. If you haven't been using dot phrases or haven't been using some form of copy and paste 7-8 month into your intern year, I am not too surprised why you are lagging behind. It's not like some of them have magical skills.

Sent from my SM-G935R4 using Tapatalk

 

[Resident0123x]

Thank you LUCPM. I will work on them immediately

 

[gutonc]

You need to go find your Epic IT office and get a refresher/training course. I would honestly use a day off for this as it's likely to save you a ton of time/aggravation down the road.

As has been mentioned before, every Epic implementation is different and what's available to me may not be available to you...or in a different place...or only in the inpatient or outpatient setting. I have privileges at 3 different hospital systems that use Epic and the implementation at all 3 is so different that I generally write notes in my own home system and then copy/paste them to the other systems when necessary.

 

[AdmiralChz]

Yeah like @gutonc said each EPIC version is different, and honestly as a physician you should focus on improving your own practices and figuring out solutions for yourself based on advice - not having others send you their dot phrases or macros. What worked for me (as a surgical intern) might not work or even make sense for you (as a ?? intern).

 

[Resident0123x]

Thank you gutonc, AdmiralChz

 

[fantasty]

Yeah like @gutonc said each EPIC version is different, and honestly as a physician you should focus on improving your own practices and figuring out solutions for yourself based on advice - not having others send you their dot phrases or macros. What worked for me (as a surgical intern) might not work or even make sense for you (as a ?? intern).

Well, agree that you need to customize your [OP's] own practice, seeing and modifying dot phrases is helpful to get you on the way. But, it's likely that having someone external email you their dot phrases may not work due to the build differences that others have mentioned. So, aside from the Epic refresher mentioned, I would expect that your senior / chief residents would have pointers and possibly a library of useful tools appropriate for your rotations.

 

[atomi]

Get a cow and type your notes during rounds. By the end of intern year I was done with notes by the end of rounds. Staying till 10 to finish notes is a rookie mistake. Copy your old forward. Delete unnecessary crap. Who cares about continuing their home hypertension meds. That doesn't need to be documented. Only document major parts of the plan, daily exam, and labs reviewed and note significant abnormal labs and imaging. 5 minutes per note max.

 

[Raryn]

Get a cow and type your notes during rounds. By the end of intern year I was done with notes by the end of rounds. Staying till 10 to finish notes is a rookie mistake. Copy your old forward. Delete unnecessary crap. Who cares about continuing their home hypertension meds. That doesn't need to be documented. Only document major parts of the plan, daily exam, and labs reviewed and note significant abnormal labs and imaging. 5 minutes per note max.

Found the surgeon.

 

[fantasty]

Found the surgeon.

Yeah... I just had a panic attack thinking about it.

 

[Dr.Acula99]

Get a cow and type your notes during rounds. By the end of intern year I was done with notes by the end of rounds. Staying till 10 to finish notes is a rookie mistake. Copy your old forward. Delete unnecessary crap. Who cares about continuing their home hypertension meds. That doesn't need to be documented. Only document major parts of the plan, daily exam, and labs reviewed and note significant abnormal labs and imaging. 5 minutes per note max.

Yes and no, I agree with omitting useless things in the plan. Then again I always include hypertension and mention what home meds are continued and held, since this makes a big impact on discharge planning. I do agree with omitting useless stuff linked hyperlipidemia, unless it's particularly pertinent.

 

[Psai]

Dot phrases are awesome when you're writing the note but my fingers are getting tired from all of the scrolling.

 

[kchan99]

For consult services, obtain templates from prior residents on the service before you start the service. For example, you would want to have a section documenting exposure and travel history in an initial ID consult note.

For continuity clinics, you should already have your own templates for various types of patients. I'm in neurology so I have had templates for headache, dementia, etc. I have paragraphs with fill in the blanks (***) that I fill in as I'm talking to my patient. That way I don't look away from my patient too much.

 

[fantasty]

For consult services, obtain templates from prior residents on the service before you start the service. For example, you would want to have a section documenting exposure and travel history in an initial ID consult note.

For continuity clinics, you should already have your own templates for various types of patients. I'm in neurology so I have had templates for headache, dementia, etc. I have paragraphs with fill in the blanks (***) that I fill in as I'm talking to my patient. That way I don't look away from my patient too much.

Agree. There were definitely consult services that preferred if you followed an organized template because it mirrored the thought process. ID. Renal. Cardiology - particularly if you have a defined service like heart failure. ICU too.

I was never smart enough to prepare good templates for common complaints in clinic though.

 

[HLxDrummer]

For in patient stuff if you open a new note that is a button that looks like a sheet of paper with an arrow on it. Click that and you can copy previous notes. It will import the previous one and automatically refresh stuff like medications, vitals, dates, etc assuming you are using a template/dot phase. Then you can update the subjective/exam/plan as needed.

 

[Raryn]

For in patient stuff if you open a new note that is a button that looks like a sheet of paper with an arrow on it. Click that and you can copy previous notes. It will import the previous one and automatically refresh stuff like medications, vitals, dates, etc assuming you are using a template/dot phase. Then you can update the subjective/exam/plan as needed.

I personally never liked using the copy forward button because I would inevitably get sloppy and forget to update a component. I'd start a new blank note with a templated dot phrase and copy/paste the individual components (exam, plan, whatever) as needed, editing as I went along. That's just personal preference though.

 

[Psai]

I personally never liked using the copy forward button because I would inevitably get sloppy and forget to update a component. I'd start a new blank note with a templated dot phrase and copy/paste the individual components (exam, plan, whatever) as needed, editing as I went along. That's just personal preference though.

I also do this. Kills me when someone else takes my patient on my day off and ****s up my note tho, especially if it's one of the midlevels who can't even put the note in the right order.

 

[kchan99]

I personally never liked using the copy forward button because I would inevitably get sloppy and forget to update a component. I'd start a new blank note with a templated dot phrase and copy/paste the individual components (exam, plan, whatever) as needed, editing as I went along. That's just personal preference though.

For copy forward, make sure your assessment/plan uses actual dates or days of the week for procedures, labs, etc. instead of today, tomorrow, or yesterday. It's probably a good idea to keep a running of lists of important labs, procedures, and key meds (e.g., antibiotics, pulse steroids) somewhere in your note that you update as you go along so your D/C summaries would be easier to write. The med list and vitals need to be update-able fields.

 

[Raryn]

For copy forward, make sure your assessment/plan uses actual dates or days of the week for procedures, labs, etc. instead of today, tomorrow, or yesterday. It's probably a good idea to keep a running of lists of important labs, procedures, and key meds (e.g., antibiotics, pulse steroids) somewhere in your note that you update as you go along so your D/C summaries would be easier to write. The med list and vitals need to be update-able fields.

Absolutely.

I never put Day X of Y for antibiotics and I never put POD #X.

I put Antibiotics started on 01/30/17, planned end date 02/10/17. Or s/p operation X on 02/05/17. Etc.

 

[J ROD]

I hate when I copy forward others notes that have no clue not to use specific lab values and other things that have to be changed daily. It makes no sense to me to be that stupid not to realize that "I have to change this crap everyday....maybe I should should say the patient has an elevated Scr under AKI and not put the actual number each day.

 

[Crayola227]

there's a function where you can abbreviate words, this helped me out because I was a ***** for abbreviations, not having to type out your most used words can help when you're trying to save every second you can on notes

eg
you type "dz" and it puts in disease
you type "impr" and it puts in "improving"
"wor" worsening

etc etc

 

[JustPlainBill]

Good luck with that --- all depends on residency attendings and how incompetent they are -- I've found an inverse relationship with the competency of the attendings and the amount of unimportant minutiae required in the note. But I digress --- dot phrases work, get a template with a basic physical exam that you realistically do (not the one you feel like you should be doing to be a complete and thorough physician but the basic minimum you do on all hospitalized/clinic patients) and roll from there -- the H&P is always a beast but put the time in on those -- the first progress note can be time consuming but after that, copy it forward, and change the details --- but beware -- some attendings will look back over previous notes, detect the copying and pitch a hissy fit --- most of us who are realistic are more interested in you knowing your patients, getting the essential elements of information needed and after you have demonstrated that you actually know what to do for a thorough H&P and we trust you enough to trim the fat, are ok with streamlining things ----

Case in point ---

One attending of mine wanted the history section in a very specific order and actually commented on it in my review --- I really, personally, don't care what order you put them but evidently, Western democracy as we knew it depended on it being in a certain order.

Another attending, when I tried to deliver the level of nit-noy detail the previous attending wanted, turned to me, stopped me in mid sentence and said,"C'mon, let's be reasonable here -- just give me the facts".

Best one ever -- working with a community attending who admitted his patient's to the teaching hospital and let the residents manage them with daily phone contact and he would round PRN to check up on us ---nicest guy ever, kind that still wore suits to the hospital; anyway, we were going to d/c a patient of his and he told us he would do the discharge summary and not to worry about it; I read it a few days later --- handwritten in fountain pen in the chart -- gist of it -- patient admitted for this, we did this, discharged home in this condition with this follow up -- see the chart if more detail required -- maybe 3-4 sentence paragraph --- that's the way it's supposed to be done -- not all this crap that no one reads anyway;

As a community physician, I have had 1, only 1, patient present within a week for hospital f/u that there was ever a d/c summary done on and the first paragraph and the f/u was all I was interested in.....


clinic notes just suck in general -- mainly used as a tool to justify a billing level, rather than containing any useful information......

 

[Bacchus]

Meh to macros for ROS/PE. IMO, in FM there are too many nuances to the ROS/PE to make macros.

Saw 20 patients today. Was out of the office 15 minutes after the last patient NOT using macros.