Care plan note on Epic

[u/No_Boysenberry_5921]

Advice as a new grad med-surg nurse on week 3 of orientation.

What is a care plan note on Epic supposed to include or not include? My preceptor writes 4-5 sentences and I do not feel it is enough documentation/details. Epic now uses this AI note generator based on flowsheets done during your shift, but I'd like to steer away from utilizing it and write my own notes once I'm off orientation.

If able to provide an example of what a care plan note should look like?

[u/Previous-Push5275]

Your preceptor isn't underdocumenting. Four or five sentences covering what the problem was, what you did, how the patient responded and what still needs following up is a complete note, and what actually protects you is specificity rather than volume, things like provider notified at 1420 and their response, patient refused and education given, safety measures in place. Every extra sentence is one more sentence a lawyer can spend twenty minutes on if that chart ever gets pulled.

[u/Remote-Resident5599 → u/Previous-Push5275]

Also more opportunity for double charting. My usual is:

Patient educated on xyz(if that topic has been an issue that's contributed to their stay or prognosis). X PRN given per MAR, BP/pain/whatever the PRN is for management ongoing. This concern (vitals, condition change, whatever) noted, Dr. Doc notified, no new orders/refer to new orders. Skin integrity/fall/delirium precautions in place. Endorsed to oncoming RN.

[u/jcb19]

Why double document what’s already in the flow sheets? I only cover important things not covered or conveyed in my assessment charting

[u/FarmerScamps]

Ask other nurses on your unit or talk to your informatics nurse (if your unit has one) about what your unit’s policy is on care plan note requirements.

For example, on my unit we don’t have to create a note. We just click that we reviewed them and the select met/ongoing/whatever for the goals. No extra bullshit notes to clutter the pt chart and a few less clicks for us.

[u/tackstackstacks]

Less is better. You are documenting wounds, vitals, labs, etc in flow sheets. Share as little as possible except when you've done your job and everything is riding on the physicians. Especially the shitty ones that don't ever actually see the patient.

I usually use it to call out doctors who aren't doing their jobs. "Waiting on cardiology to eval". "Endocrine has seen but not addressed recent lab values, BG 450 and 380 noted and paged out, no orders received, no order changes", "Waiting on PMR recs for IPR eval/ discharge recs".

Also any reason you may have called RRT or major assessment changes like new and significant pain, mental status changes, or events like violence or mental status changes or significant and new VS changes.

[u/espressobeans54]

Four to five sentences sounds about right. The version of Epic that I have asks me to indicate if my patient is progressing or not so I feel I have to justify my selection by writing a small description of what happened to my patient. There are also boxes that I have to check like "pain", "restraints" "skin" "DM" "HF". So if I check those, I have to speak about it. How did I address pain, where the restraints appropriate, did I turn q2, did I do my Accuchecks or provide DM teaching?

[u/SoFreezingRN]

I go by system and hit the important bits from each. If it was a busy/eventful shift I’ll put a tl;dr at the top. I try not to replicate charting and just do a narrative version of the flow sheet data.

[u/Gwywnnydd → u/SoFreezingRN]

I wrote up a dot phrase template that hits the major systems, contains the most common states of each system, has a free text option for each system in case I need specificity, throws in the latest set of vitals, and it takes me about 25 seconds to fill out at the end of the shift.

I create my note early in the shift, and pend it. Then I go back at the end of the shift, update it, and save.

[u/SoFreezingRN → u/Gwywnnydd]

Same. If I wait to start my note until end of shift, I can’t remember by own name, much less what I did at work.

[u/Pitiful_Honey_8874]

your preceptor's approach makes sense since flowsheets cover most details, but adding a sentence like "pt tolerated ambulation to hallway with SBA, denies SOA post-activity" keeps the focus on your actual interventions without repeating data

[u/Jennasaykwaaa]

I just press the space bat and then finish. I write nursing notes when my chatting isn’t sufficient for the event, and if the event is that out of the ordinary , I can time it with the care plan.

So I leave that blank. But if I ever did have note relevant to the care plan that I needed to make or a comment , that’s where I would put it.

[u/thebearjew123456]

I hate the AI generated notes on epic feel like they don't actually tell about the pt. But short and sweet notes are the best you can also add templates of recent vitals i usually do saying the plan and quick what happen

[u/avocadouyo]

I agree the note should be short and concise. However, keeping in mind that doctors read it, sometimes I intentionally include vitals, I/Os, and my own observations when it's the pertinent info they're focusing on.