Practical Tips for EMR Efficiency as an Intern

One of my goals during intern year was to become more efficient, and particularly in Epic, which was a new EMR for me when I started residency. Here, I discuss various customization, organization, and efficiency tips I’ve encountered over the course of intern year. I’ll skip past the common efficiency tricks people widely use like smart phrases, note templates, and wild cards. In this post, I’ll go over how I set up my patient lists and tabs to optimize my workflow.

Setting up the patient list home page

This is how I set up my patient lists (as primary team) to improve my organization.

• There are only a few columns you actually need on the patient list, and others that are helpful but unnecessary.

  • Columns you need: Patient Name & MRN, Unit/Room/Bed, Age/Sex/DOB, Code Status

  • Columns that are super helpful: New notes (flag), New results (flag), Consult note (flag), My Sticky Note Text, RN, Level of care

  • Columns that are nice to have but not necessary: Primary problem, Isolation status, Diet order, Length of stay, Discharge order status, Discharge summary

• If you know someone who has a nice layout, you can copy their column template by typing in their list ID, which can be found under properties. You can also use this trick to copy your own list template into new lists you make.

• I like to number and letter my lists 1a, 1b, 2a, 3a, etc. based on my needs. Here are some examples:

  • 1a MY PATIENTS - the list of patients I’m currently taking care of

  • 1b NEW PATIENTS - new patient from overnight; sometimes I use this list as an alternate list when I don’t want to add them to the list above

  • 2a [service] - the “full” list of patient on our service. I drag the automatic system-built list for my service under this list and will also include patients who are on our service but not on the official list yet (like those still in the ED) or patients who are in the process of transferring to our hospital.

  • 3a RECORD - all the patients I have taken care of this year (I ended the year with almost 350 patients). I made this mostly for my own curiosity to see how many people I would take care of as an intern.

  • 3b PGY1 eyes - all the inpatient eye patients I took care of or saw as an intern on medicine and ED services (I ended the year with about 50 patients, which I feel like is quite a bit for a mostly medicine intern year — this doesn’t include the patients I saw on ophtho rotations because those were all outpatient and some at other sites).

• On my sticky note texts, I often write down learning points or interesting pathologies relevant to the patient. Sometimes I’ll include which rotation I saw the patient on or which attending I saw the patient with to help me remember my patients.

• Additional system lists I include under my Favorited Lists

  • ED list

  • Transfer Center list

Searching Lists

When I was covering multiple services on Night Float, I utilized a single list with all the patients across services rather than look at individual lists for each service. When a make a single list, I make sure to print it out with the patient names organized alphabetically along with a column that displays the service for the patient. This way, I can cut down on all the paper I carry overnight and also easily find a patient on my paper list when I’m not near a computer. Having a conglomerate list also helps to easily search patients: use the list search bar by setting the search to “Search this List.” Similarly, you can find any admitted patient by setting the search to “All admitted patients.” This comes in handy when receiving a new transfer or admit that has not populated your service’s official list yet.

Setting up my tabs in the patient chart

This is how I prefer to organize my tabs to improve my workflow.

• Overview of tab order

  • Summary

  • Notes

  • Chart Review

  • Manage Orders

  • Results

  • Admission

  • Discharge

• Summary tab

  • Order of mini tabs (and abbreviation I use): Overview, Order Hx (Orders), Patient Calendar (Cal), Vitals (V), Cardiovascular data (CV), Resp accordion (R), Intake/Output (I/O), Meds History (MAR), Labs since admission (Lab), Radiology Results (Img), Fever (Fev), Blood Administration (Bl), Glucose (Glu), Pain Management (Pain), Weight Monitoring (Weig), Springboard report (Onc), HD/CRRT/UF/Apheresis (Dialysis)

    • This is the order I click to pre-round. I will get into more details of how to pre-round in another blog post (if I get around to it).

  • Within the Overview mini tab, I modified the report layout to include four most pertinent boxes at the top: 1) Lines Drains and Airways (in graphic form that shows an outline of a human), 2) Vitals (in a graphic form to show daily trends), 3) Sticky Notes to Treatment Team (sometimes includes important social information and phone numbers), 4) Signed in Clinicians (which use primarily to look up the most updated bedside nurse, phone numbers, and notably the shift start and end times to ensure I contact the right person).

• Notes tab

  • I always set my notes tab to show the Service in large text rather than the author name. It’s much easier to skim the list of recent notes to see the the services that have written notes recently rather than a bunch of names that you might not recognize.

  • After reviewing notes, I click “Mark all as not new” or Alt-K to clear the new note notification icon from my patient list column.

  • To quickly compose and copy forward the last progress note written by me, click “My last note” (Alt-M) and “Copy” (Alt-Y), essentially Alt-MY.

• Chart Review tab

  • Under Encounters, my default filter shows ED visits and Admissions only. This helps me quickly chart review a new admit and find their last hospital encounters and recent problems. Then I click through the other filters to find recent office visits, upcoming visits, and telephone encounters.

  • I drag the “Media” tab to be right after “Imaging” for easy access.

• Manage Orders tab

  • I typically sort my orders by “Order Type” which is the system default. However, sometimes I sort by therapeutic class if a patient is using multiple medications within a therapeutic class, such as analgesics or GI agents.

  • I also recommend making preference lists and order sets based on what you frequently order. For instance, I have a preference list called “Admit checklist” which includes orders like SCDs, oxygen, nicotine patch, antiemetics, and PRNs like artificial tears, melatonin, oral hydration gel, and apply ice. Many of the items here are included on my admission order set, but might not be included on other people’s admission order sets. This preference list pops up at the top of my order search so it’s super quick to place a common order. In regards to order sets, I have several for common orders I place, like anemia, hemolysis, TLS, refeeding, urine lytes, etc. Much easier to place common orders with minimal clicks!

• Results tab

  • I always time mark my results after I have seen them to clear the notification on my patient list.

  • The search bar under the results tab can be used to find any previous result recorded in the chart.

  • Results can be filtered through the outline menu. For instance, clicking on “Microbiology” brings up all relevant micro results, which is super useful for tracking culture data efficiently. Clicking on “Radiology” will bring up all previous imaging in one filtered presentation.

  • Each lab value can be trended. Right click on the box and select “Dates as Rows” to find all previous values. For instance, this is useful for finding baseline creatinine for a patient who comes in with kidney injury or baseline sodium for a patient with hyponatremia.

  • Under the “Not Resulted” section, I like to click the bell to alert myself of specific results that might change management. When these results come out, they show up in the inbox so I don’t miss it.

• Discharge tab

  • I changed the order of my layout. This is the order I have that has dramatically improved my discharge workflow:

    • Preview After Visit Summary - at the very top so I can easily preview the AVS after changes are made to the discharge paperwork

    • Prescription Routing - This is where I would default all of the discharge meds to “No Print” for patient who are going to nursing facilities after discharge. This way, I avoid having to manually click “No Print” on every single discharge med.

    • Order Reconciliation

    • OARRS Report - this is the only place I know to find it

    • Discharge Instructions - with SmartPhrase speed buttons so that I can import my discharge template with one click without having to type out the dot phrase

    • Discharge summary - as above, with SmartPhrase speed buttons so that I can import my note template without having to type the dot phrase every time

Bonus

Three highly underutilized parts of the chart are the patient information side bar, the sidebar summary on the right, and the bottom bar under patient lists. Here’s a few uses for these areas:

• Patient information side bar:

  • Hovering over “New Results” displays all the new lab and micro results in one place without having to click into the results tab. The results can also be cleared from the side bar, but once a the notification is cleared those results (now considered seen) will not be accessible form the side bar any longer.

  • Hovering over “Active Meds” displays all the current meds without having to click to the orders tab or medication history tab. This is a quick place to look up what scheduled meds the patient has missed and what PRNs the patient has recently used.

• Sidebar summary on the right:

  • Shortcut to writing handoffs allows for the note to be open while handoffs can be written

  • Shortcut to Dispense history allows for a quick review of recent meds that have been dispensed at pharmacies.

• Bottom bar under patient lists:

  • The tabs here can be set up like the mini tabs in the Summary tab. Notably, it’s super useful to have the human outline version of the lines/drains/airway here as well as the signed in clinicians box. This makes it super easy to message the patient’s nurse without clicking into the patient’s chart.

Hope this helps!

emxu