EPIC EMR question

[Lost in Translation]

Quick question:

Is there a smartphrase for the EPIC EMR that populates the detailed I/O for the last 24h in a table format like it appears in the actual flowsheet tab for I/O?

---

Members don't see this ad.

 

[Crayola227]

Quick question:

Is there a smartphrase for the EPIC EMR that populates the detailed I/O for the last 24h in a table format like it appears in the actual flowsheet tab for I/O?

No, this is a major weakness and the reason why that is one of a few tabs you have to hit manually in the am.

 

[NotAProgDirector]

Huh?

.IODETAILS - Full table, with colors
.IOBRIEF - just a summary

also:
.IONET - net I/O since admission

(these only show the last 24 hours, is that the problem)

 

[Redpancreas]

Quick question:

Is there a smartphrase for the EPIC EMR that populates the detailed I/O for the last 24h in a table format like it appears in the actual flowsheet tab for I/O?

This may be institution specific as each EPIC is a bit different at each institution but NAPD above is on the money with what worked at my place. I used .iobrief BUT careful with trying to dotphrase away work. The only reason I had that is so that my note had the data. The sourcing for some of the data is suspect and needs to be verified by actually reading the flow sheet (mastersource that NAs/RNs document their findings in).

 

[Lost in Translation]

We have those above mentioned dot phrases however when you cross check the values with what’s in the actual flow sheets, it doesn’t always correlate (in fact, it rarely does).

Dang. Thanks though!

 

[gutonc]

We have those above mentioned dot phrases however when you cross check the values with what’s in the actual flow sheets, it doesn’t always correlate (in fact, it rarely does).

Dang. Thanks though!

Alternatively, just stop putting that s*** in your note. It's in the EMR. No need to duplicate/triplicate/quadruplicate information. I promise nobody is going to your note specifically to find the I/Os.

 

[Redpancreas]

Alternatively, just stop putting that s*** in your note. It's in the EMR. No need to duplicate/triplicate/quadruplicate information. I promise nobody is going to your note specifically to find the I/Os.

This is an underrepresented point. On one end, attendings likely go to department meetings where documentation specialists and billing have crafted a note template and the attendings are told to tell us to use XYZ because it optimizes billing. No note template optimizes everything: billing, chart review, and communicates things effectively to readers in the hospital that day and to outside readers at a later date.

These last few months I’ve involved myself in some volunteer work looking through legal documentation for various lawyers/etc. because I’m an idiot like that. What I’ve noticed is that documentation reflects how we are seen. Legal teams will use it as ammunition and say things like if you wrote XYZ in your note how can we trust ABC. Typical notes are full of garbage auto populated filler and Gutonc is right that unless you absolutely have to, it’s better not to put things in your note that aren’t able to be changed on a daily basis. At the same time, if your attending wants something based off a template, just do it.

OP is right that IObrief/etc. is inaccurate. The best way is to review IOS, if it looks stupid/inaccurate, go to the flow sheets and try to figure out if there was a bad entry and if not and you need to know (diuresis/worsening AKI), go to the nurses station and ask what happened overnight. You only have so much time everyday to chart review so pick your battles and don’t do this with every one of your patients or else you won’t have enough time to finish rounding in the AM.

 

[Lost in Translation]

Alternatively, just stop putting that s*** in your note. It's in the EMR. No need to duplicate/triplicate/quadruplicate information. I promise nobody is going to your note specifically to find the I/Os.

Unfortunately the culture at my place is to write down 24h I/Os somewhere on the rounding packet to bring it along.

 

[Crayola227]

What people forget is that as an intern you are absolutely responsible for all those little values on every single patient, and just eyeballing things in the am and having the right gestalt about fluid status frequently isn't enough as it might be for a senior or attending.

And that one way for an intern to shorten prerounding and preparing data for their presentations is to have as many values as possible pulled into an EPIC template.

In fact, I had a rounding report and lists that I printed that pulled in a lot of things for allowing me to present that were never pulled into my actual daily notes.

I had it down where I could print it, and only had to manually check like 4 or 5 things per patient ij the am and take note on the print out. Iirc it included tele, a tab on CBG/insulin, a tab on I/O, and nursing notes and consult notes.

And don't tell the interns not to bother reading nursing notes. That's a good way for them to end up majorly embarrassed at rounds and in trouble.

 

[Redpancreas]

Unfortunately the culture at my place is to write down 24h I/Os somewhere on the rounding packet to bring it along.

Honestly that’s not that bad. I had an acronym for what I’d write in the square box of my paper scut. It was VIPLIP. Vitals(trends), IOs (including BMs), Physical findings (you’d be surprised what you forget), Labs (BMP/CBC), Imaging (interval XR, EKG, etc.), and Procedures/Surgery results (cath/colonoscopy, biopsy debridement). These are things you shouldn’t just glance at but review carefully before you write them down. This isn’t to be confused with what I’d review daily which was its own acronym. For the more wordy stuff like colonoscopy results don’t try to dictate the report onto the page but summarize the impression in two words. When doing that make sure you specify that in your oral report that you read it, the gist is <insert two words>, and pull up the EMR report and read the quick impression briefly.

 

[Redpancreas]

What people forget is that as an intern you are absolutely responsible for all those little values on every single patient, and just eyeballing things in the am and having the right gestalt about fluid status frequently isn't enough as it might be for a senior or attending.

And that one way for an intern to shorten prerounding and preparing data for their presentations is to have as many values as possible pulled into an EPIC template.

In fact, I had a rounding report and lists that I printed that pulled in a lot of things for allowing me to present that were never pulled into my actual daily notes.

I had it down where I could print it, and only had to manually check like 4 or 5 things per patient ij the am and take note on the print out. Iirc it included tele, a tab on CBG/insulin, a tab on I/O, and nursing notes and consult notes.

And don't tell the interns not to bother reading nursing notes. That's a good way for them to end up majorly embarrassed at rounds and in trouble.

This is right on the money. When you hear intern, think of the guys getting lawyers coffee and be glad you’re not doing that and are writing these numbers down instead. There are some interns who manage to convince attendings they have their **** together and can get away with just eyeballing stuff and doing the fake-it-till-you-make-it, but as the intern this is deff something you need to do.

The thing though @Crayola227 is that all these attendings are anal about different things. An older physician may not care what’s in your note and just co-sign an auto generated dotphrase at the bottom but then waste the afternoon pimping you on clinically irrelevant factoids. A younger hospitalist might pull you aside and tell you they prefer not to see XYZ in notes and you can’t just rebut and say your style in the AM is to put your note in presentation order and read off your iPhone EPIC app because ultimately they’re the ones filling out the billing for the note and they don’t care what helps you present if it makes their job harder. You can try finagling and trying to be fancy with the EMR to make things work but it hardly helps. The closest thing I’ve found to automating the AM presentation without using the written note is using the ?signout section of epic to cue you. The signout section allows you to do dot phrases and you can add them to your smart columns and print off as a rounding sheet. It won’t be in the more, but other people have access to that signout column I think so it may get deleted. That said though, you’re basically replicating your work you wrote anyways on your scut sheet so it’s better to just stick with the scut sheet.

The key to all this is to not play mad scientist everyday and change your system around. Spend the first two weeks of intern year figuring out all the features of the EMR and figuring out what is efficient for you. What is the method where you miss the least, but don’t duplicate work. After that, changing your system will just do yourself a disservice as it’s a distraction from other critical things you need to learn and you’ll never get used to the habits of one system. If an attending wants something changed, find a way to incorporate with the least possible change to your framework.

 

[gutonc]

Unfortunately the culture at my place is to write down 24h I/Os somewhere on the rounding packet to bring it along.

That's fine. Just pick a # then. If Epic spits out 17 different values, you can't be responsible for that. Choose one and report it.

 

[NotAProgDirector]

Very interesting. I don't use these smartlinks much, and never noticed they don't work as you'd want.

It's actually easy to fix them, if you can ask someone on your build team to do so.

For .IOBRIEF, the fourth parameter in the smartlink code is the start time. if blank (which is the default), the smart link uses the current time and looks back 24 hours. So, if you want the 7AM - 7AM I/O, it works just fine at 7AM. But if you write your note at 10AM, you'll get a 10AM - 10AM I/O. This can be fixed by setting that fourth parameter to whatever standard start time you want. If it's set to 7AM, then anytime the smartlink is used after 7AM today, it will report 7AM yesterday - 7AM today. But if you write a note at 6AM, then you'll get 7AM two days ago to 7AM yesterday. So choose your start time wisely.

For .IODETAILS, the solution is somewhat similar. The fifth parameter is "lookback intervals". This smartlink uses "shifts" instead of hours. We have three I/O shifts -- 7A - 3P, 3P - 11P, and 11P - 7A. The smartlink always shows the current shift, and then the rest of the shifts for the day (which are of course blank, since they haven't happened yet. Which is dumb). If left blank (which is the default), then the first shift of the day is shown. So if you use it at 10A for a note, all you'll get is the I/O from 7A - 10A. But we can set the lookback to the number of shifts prior to today that you want -- so in our case, if set to 3, you'd get all of yesterday's I/O, plus anything today also, all in a table. You can't get more than 24 hours, even if you set the lookback to more than the number of shifts in 24 hours.

Both tweaks are easy to do for a builder. There's no way to override them yourself, I looked at the raw code.

 

[Lost in Translation]

Very interesting. I don't use these smartlinks much, and never noticed they don't work as you'd want.

It's actually easy to fix them, if you can ask someone on your build team to do so.

For .IOBRIEF, the fourth parameter in the smartlink code is the start time. if blank (which is the default), the smart link uses the current time and looks back 24 hours. So, if you want the 7AM - 7AM I/O, it works just fine at 7AM. But if you write your note at 10AM, you'll get a 10AM - 10AM I/O. This can be fixed by setting that fourth parameter to whatever standard start time you want. If it's set to 7AM, then anytime the smartlink is used after 7AM today, it will report 7AM yesterday - 7AM today. But if you write a note at 6AM, then you'll get 7AM two days ago to 7AM yesterday. So choose your start time wisely.

For .IODETAILS, the solution is somewhat similar. The fifth parameter is "lookback intervals". This smartlink uses "shifts" instead of hours. We have three I/O shifts -- 7A - 3P, 3P - 11P, and 11P - 7A. The smartlink always shows the current shift, and then the rest of the shifts for the day (which are of course blank, since they haven't happened yet. Which is dumb). If left blank (which is the default), then the first shift of the day is shown. So if you use it at 10A for a note, all you'll get is the I/O from 7A - 10A. But we can set the lookback to the number of shifts prior to today that you want -- so in our case, if set to 3, you'd get all of yesterday's I/O, plus anything today also, all in a table. You can't get more than 24 hours, even if you set the lookback to more than the number of shifts in 24 hours.

Both tweaks are easy to do for a builder. There's no way to override them yourself, I looked at the raw code.

Thanks for this insight.

 

[nikolaite]

These last few months I’ve involved myself in some volunteer work looking through legal documentation for various lawyers/etc. because I’m an idiot like that. What I’ve noticed is that documentation reflects how we are seen. Legal teams will use it as ammunition and say things like if you wrote XYZ in your note how can we trust ABC. Typical notes are full of garbage auto populated filler and Gutonc is right that unless you absolutely have to, it’s better not to put things in your note that aren’t able to be changed on a daily basis. At the same time, if your attending wants something based off a template, just do it.

It is worth considering error drift when populating notes. I’ve yet to see an actual working policy to purge this phenomenon...and it is a credibility destroyer at some levels.

I have also noticed doing chart reviews that some providers pull vitals from various times in the patient’s record, like a cross-covering doc or specialist pulling the 2 hr prior vitals and entering those as current into his personal eval notes. Or they have their mid levels write up personal evals (that obviously didn’t occur) and sign them hours later.

I get that attending docs and other specialists are busy, but it’s like they don’t know about records audit trails and that this might not look good if it came in front of the Medical Arts Board or even a civil court. 🤷‍♀️