Our MD Tech Tip article this week is find out how to chart sooner 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 train our residents on find out how to chart sooner and be extra environment friendly on shift. Via hours of lectures I’ve given them, I’ve tweaked my instruction accordingly based mostly 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 wished to current that can make your subsequent scientific day extra environment friendly. Particularly, I give attention to information gaps I’ve seen in senior residents when studying find out how to chart. Whereas a number of the following may seem like refined workflow modifications, 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 types really take for much longer. Means too many clicks and variations. So for that belly ache affected person, think about using the “Sickness” HPI type as an alternative of “belly 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 offers you the factors you want in your degree of service to be excessive (1-5). I can’t emphasize this type 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 soar into the Narrative field and can dictate just a few traces accordingly. Complete 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 the most effective. Transcription just isn’t best. For my part, having to attend for a transcription service after which evaluate 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. In case you are not aware of actual time dictation, it’s the capability to make use of a dictation software program, resembling Dragon dictation, along side the EHR. For my setup, actual time dragon dictation is constructed proper into epic, and we have now energy mics that enable us to dictate on the press of a button proper into the chart. You possibly can 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 might all the time maintain typing sooner than I might dictate. For a full 12 months that our hospital turned on dictation I refused to change over, feeling that I might kind sooner. Lastly, a fellow school member satisfied me to at the very least simply give it a attempt 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 lots of 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 sooner. Publish switching over to actual time dictation, I used to be capable of end charts rather more simply on shift and have nearly each chart performed previous to the tip of a shift. For those who’re a kind 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’re going to get assist out of your administration just by saying it can assist get charts performed sooner 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
Set up your medical choice making(MDM) with a normal dot phrase. The extra normal 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 along with your chart, the extra time and complexity you’re including. Hold it easy (not all the time attainable 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:
Key medicines administered within the ER: @[email protected]
Medical Resolution Making:
Key discharge directions:
Clearly, set up your normal dot phrase in your medical choice making or evaluation and plan accordingly. No matter you resolve, simply be sure to are conserving it normal. It’s a lot simpler to go and delete sure components of your normal 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. Once 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 nicely when you’ve gotten a two monitor arrange. When enabled, floating home windows are a good way to optimize charting by permitting you to multitask and in addition citing an incomplete word each time you’re in a affected person chart. To entry floating home windows, go to your word author. On the “edit word” tab that reveals 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 enables your word to point out up on a separate monitor, permitting you to do extra chart evaluate whilst you’re filling out your word.
My favourite effectivity function from that is that after it’s enabled, each time you open the sufferers chart, your word pops up in case you have not pended it or accomplished it. It’s a continuing reminder to complete your word or replace it.
Ensure your entire “wrenches” are optimized!
Epic has tiny wrenches all through many of the screens you’re in. These wrenches are vital as a result of they help you customise each display and the way knowledge 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 wish to seem in entrance of you. This may help you entry historic check outcomes higher, help you see important indicators higher, and rather more. I can’t inform you what number of instances I’ve discovered merely reconfiguring a residents wrenches permits them to save lots of just a few 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’ll be able to. Even when it’s simply filling out the HPI, ROS, and the bodily examination. You don’t wish to finish your scientific day or night time with an inbox of charts which are clean!
Do you’ve gotten 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 checklist!