I was so confused during my first few weeks as an IM intern. The hospital environment was new, ande the electronic medical record(EMR) was unfamiliar. With the help of some awesome seniors and savvy friends, I eventually developed my way around our EMR. Rest assured, you will create a system that works for you, too, but until then, here is something you can use as your starting point:
Physical exam first:
Please ensure you have physically seen this patient after your sign-out and that the patient is stable. No amount of computer-based reviewing can compare to talking to the patient and performing a head-to-toe physical exam. You ask the patient how their night was, whether they slept well, had dinner, had any pain or discomfort, urinated well, or when their last bowel movement was.
Once you have done your bedside visit, you settle and sip your coffee while you review the chart.
Begin with questions:
By doing so, you will have questions to begin with. E.g.,
Why does the patient have a fever?
S/he has not had a bowel movement for two days! Are they on a bowel regimen?
The patient is not moving around much and also has cancer. Are they on a DVT prophylaxis?
Being treated for CHF exacerbation. Are we trending their weight? Is urine output reflective of appropriate diuresis?
Why is s/he having abdominal pain etc.?
Your objective of chart review is to
1) Answer these questions.
2) Make sure the orders are correct and as planned
3) Check if consulting teams have something to add. Did we follow their recommendations? Do we want to?
4) Make sure clinical findings are corroborated with objective data.
Steps:
- Log in to the Epic system using your username and password.
- Make sure you use the proper context: e.g., Inpatient Medicine
- Once you are in, don't forget to sign in to your patients
- By doing that, you make others aware that you are taking care of this patient so that they can give you information if they have any.
- Navigate to the patient list and select the patient you want to review.
- Ideally, you should have created your epic list with the properties you want to be displayed on your epic board.
- If your epic board is set up correctly, you see your patient's vitals, confirm their location, and you will be indicated that there are new labs and new notes for you to review. You might only know what that means if you have had a little experience with epic. That's fine. You will learn that eventually.
- Review the H&P (Go to notes, click on H&P) if this is a new patient. You would have already been briefed on their condition during sign-out, and you also would have already spoken to the patient during your morning bedside visit.
- Is it a red note (observation patient) or a blue note (full admission patient)
- If there is a discrepancy between what you heard in the sign-out and what you see now, please inform your senior. E.g., if this patient was signed out as a chest pain ACS ruled out observation patient ready for discharge, but the H&P is a blue note, you might have to downgrade this patient's status to observation before discharge within 24 hours.
- Avoid scrolling down and reading just the assessment and plan. Everyone has a different style of writing H&P. Some might prefer to note some minute details in the HPI section in the top part of the note.
- You might want to note down the primary diagnosis, pertinent positives and negatives in history and physical exam supporting the diagnosis, and the labs supporting the diagnosis from the H&P.
- Check the patient's lab results and imaging studies.
- Make a habit of expecting/predicting values in the labs before you open them. It will help you remember the values and their importance.
- Make a habit of reviewing images before reading the radiologist's assessment. If there is a finding that the radiologist describes but you don't see in the image, go back to the image and try to find it again.
- Asking your senior, attending, or even the radiologist to help you point out the findings is the best way to learn about chest x-rays and CT scans.
- Review the patient's progress notes and documentation from other healthcare providers involved in the patient's care.
- Sometimes precious information can be gathered by reading nursing notes.
- Assess the patient's current orders and compare them to the sign-out
- We use the typed sign-out. It has its advantages, but it is error-prone. Refrain from assuming your patient is on the medications the sign-out states. Check in the order section if those are ordered. Check if the dose is correct. It improves patient care and helps you remember management, drugs, and doses.
- Also, make sure your patient is getting what is ordered. DVT prophylaxis, home psych medication, and Bowel regimen are among the most commonly missed orders. Look in the Event log or the MAR section to find out when was the last time your patient received that medication.
A lot of these steps seem trivial or even redundant. I found redundancy to be very helpful during medicine ward and MICU rotations. My system won't be ideal for you. You will develop your system with your own efficiency hacks as you climb the residency ladder. GoodLuck!