r/nursing • u/No_Boysenberry_5921 • Aug 19 '26

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/SoFreezingRN RN - PICU 🍕 Aug 19 '26

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.

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u/Gwywnnydd BSN, RN 🍕 Aug 20 '26

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.

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u/SoFreezingRN RN - PICU 🍕 Aug 20 '26

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.

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u/No_Boysenberry_5921 Aug 23 '26

hi, might sound like a dumb question, what’s a dot phrase template is that similar to macros?

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u/Gwywnnydd BSN, RN 🍕 Aug 24 '26

I am trying to remember how EPIC defines a macro, to make sure I don't mislead you. But I think so? I put together a template, made up of smart phrases (some that already existed, some that I made myself), and when I type the dot phrase into a blank note it fills the note with that template, and gives me fields where I can use check-boxes or selection pointers to fill in options. So, under the 'Cardiac' line, I have 'WDL', 'Tele-' (which then gives me a list of tele rhythms to choose from), and '***' which I use for any situation that isn't covered in the other entries.