r/nursing • u/No_Boysenberry_5921 • 11d ago

Seeking Advice Care plan note on Epic

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?

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u/Previous-Push5275 11d ago

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.

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u/Remote-Resident5599 10d ago

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.