The a-z’s of Epic: a housestaff Survival Guide By Rondeep Brar, md

This guide is organized into three sections: “Getting Started” helps the user with logging in/out, creating patient lists, and assigning treatment teams. “The Basics of the Epic Chart” orients the user to the format of Epic and the basic layout of the inpatient chart. The bulk of the document is the third section, “Performing Specific Tasks,” which provides step-by-step instructions for 26 (hence the “A-Z” reference) critical Epic tasks.

It is my hope that the strength of this guide will be enhanced exponentially through collaboration/teamwork. Its structure as a Wiki document allows it to be edited by you, the housestaff, with more efficient ways of performing tasks and with methods for completing new tasks as Epic continues to evolve.

If you are entirely new to Epic, it may be useful to view this document while experimenting in the “Epic Playground” software. Practice is the best way to become efficient with the Epic software.

Thanks for reading! Feel free to e-mail me with questions/comments/suggestions at rbrar@stanford.edu.
List of topics covered in this guidebook (in order presented): logging in/out, using/changing login contexts, creating patient lists, assigning treatment team, adding patient summary tabs, admitting from emergency room, admitting from clinical decision area, admitting from intensive care unit, direct admissions, placing active orders in the emergency room, printing patient lists, reviewing vitals, reviewing labs/microbiology, reviewing imaging, writing progress notes, writing procedure notes, writing death notes, using note templates, locating last discharge summary, efficiently searching outpatient chart, reviewing inpatient medication history, reviewing outpatient medication history, reviewing inpatient pain medication use, determining transfusion history, determining insulin use, antibiotic history, reviewing overnight orders, using order sets (for insulin, pca, comfort care, heparin infusions, and post-procedure labs), creating note templates, borrowing note templates from other users, discharging home, discharging to skilled nursing facility, arranging home antibiotics, arranging home oxygen, arranging home nursing, providing durable medical equipment on discharge, and writing discharge summaries.
Section 1: Getting Started
Logging In
1. Log in using your unique userid and password.

2. Under “department,” choose either “MEDICINE SPLTY [9991019]” or “GENERAL MEDICINE SPLTY [9991010].” These settings are your “login context.” Depending on which login context you use, Epic will personalize your display and the options available to you.

Rather, click either “Log Out” or “Secure.” Both will securely exit your account from Epic. With “secure,” if you log back in, you will return to the same screen or patient chart you exited from, whereas if you “log out” you will start back at your home screen.

2. Click on “Patient Lists.”

3. Click on “Create.”

4. In the “Name” section, type in your personal list name.

5. Don’t click “Accept” yet. If you do, your patient’s won’t display correctly on Epic. You first have to tell Epic what data columns to display for each of the patients on your list.

6. To do this, click on “Copy” after you have typed in your list name.

7. From the choices given, scroll down and select “TEMPLATE PHYSICIAN” and click “Accept.”

8. You will now see several items, including “bed.” “patient name,” etc displayed in the “Selected Columns” area. These are the data that Epic will display for the patients on your list. You can remove specific data columns by highlighting them and clicking “Remove” to suit your needs.

9. Finally, click “Accept” to finish creation of your custom list.

10. You will now see your list appear under “My Patient Lists.” You may repeat this process to create multiple lists.

2. Now expand the “MD Primary Team” folder and you will see a list of all the primary teams in the hospital. Cardiology, PAMF Medicine Wards, Stanford Medicine Wards, Team T, Bone Marrow Transplant, Hematology, Oncology, the Medical ICU, and nearly every team in the hospital is listed in this section.

2. Scroll down to find your patient of interest. Place the cursor over your patient, right click, and select “Treatment Team.” You may already see some ER nurses, residents, and attendings that have assigned themselves to the team.

3. To add yourself to the team, click on the “Treatment Provider” box under “Treatment Team” and type “tt” and press enter. Scroll down and select your specific team. In our example, we would scroll down and select “TT MED UNIV 1A.” Click “Accept.”

4. Under “Relationship” type “Primary Team.”

2. Click on the monkey-wrench icon at the far right.

3. Scroll down to the first blank “Report” field and type “ip” and press enter. A list of possible tabs will appear. Choose your tab of interest and click “Accept” (most of the tabs you will use will be titled “IP ACCORDIAN ####” where #### refers to the subject of interest. The tab will now appear under your “Patient Summary” display.
Tip: If your tab still does not display under “Patient Summary” after following the above steps, try to click the “>>” icon on the right-side of the “Patient Summary” display. This will display all additional tabs that do not fit on your current screen view.
Section 2: The Basics of the Epic Chart
Now that you know how to log in, change your log-in context, and set up your patient lists, you are ready to review the Epic Chart. We will point out the basic features of the chart here. More details regarding specific tasks and advanced functions will be discussed in the next section.
- Log in to Epic and select any patient (by double-clicking) to open their chart.

- Below is a brief description of each tab in the first column of the patient chart, beginning with “Patient Summary.”

Under “orders” an organized list of active medications, labs, nursing orders, and imaging is displayed. If one needs to discontinue or modify an existing order (i.e., change medication dose/frequency, cancel an x-ray, increase a cbc from q12 hrs to q8hrs, etc, this is the place to do it). New orders can also be placed here, but may be done more quickly using the “order entry” tab. This section is best to modify or discontinue existing orders.

Under “order sets” various orders may be placed that come in pre-packaged bundles. These include insulin sliding scales, insulin drips, anti-coagulation protocols, procedure-related labs (e.g. thoracentesis, paracentesis, lumbar puncture, etc), comfort care protocols, and diagnosis-related protocols (e.g. sepsis), among several other entities.

Under “Summary Line” you may enter a short description of the patient for purposes of cross-cover and your daily rounding report (i.e., the “one-liner”).

2. Open the patient’s chart.

3. Click the “Admit Order ED” tab.

4. Click “Floor Orders.”

5. Click “Order Sets.”

6. Type in “admit” and press enter. A list of pre-defined admission templates will pop-up.

7. Choose the admission template of interest. On the wards this will be “IP MED GENERAL ADMIT.” On cardiology it will be “IP CAR GENERAL ADMIT,” and in the ICU/CCU it will be “IP ICU/CCU GENERAL ADMIT.”

8. Click “Open Order Sets.”

9. Complete the order set.

10. When finished, click on “Sign & Hold” at the bottom to sign and pend your orders. A dialogue box will open and list “Patient Transfer” under “Reason for Holding.” Leave this unchanged and click “Accept.” When your patient arrives to the floor, your pended orders will be released by the accepting nurse.

If an additional dialogue box pops up asking for the names of an authorizing/supervising provider, enter your attending’s name.
Tip: The E.R. will place an “admit to inpatient” order after speaking with the admitting medicine resident. The intern’s duty, then, is to evaluate the patient and place preliminary “signed and held” orders as above. Bare bones or “skeleton orders” can be placed relatively quickly to keep patients moving through the ER. Just be sure that important labs, imaging, and medications are ordered/reviewed early to preserve patient safety. And remember you can modify your orders at any time.
Tip: As you complete the order set, you will be asked to either continue, discontinue, or modify existing orders that have been placed in the E.R. Pay particular attention to medications here (for example, the ER often uses higher and more frequent doses of narcotics than we do on the floor).
B: How Do I Admit a Patient from the Clinical Decision Area (CDA)?
1. Locate the patient in the CDA. To do this, click on the “Patient Lists” tab, expand “System Lists,” then expand “Emergency Department,” and then click on “Clinical Decision Area.” These patients will typically be on the C1 ward of the hospital at present.

2. Assign the appropriate treatment team and open the patient’s chart.

3. Follow steps 4-10 in section A.
C: How Do I Admit a Patient from the Intensive Care Unit (ICU)?
1. Locate the patient of interest. Under the “Patient Lists” tab, expand “System Lists” then “Nursing Units.” Stanford ICU patients are located either in the “East” or “North” ICU on the 2^nd floor of the hospital. These correspond to the “E2” and “NICU” lists, respectively, under “Nursing Units.”

2. Assign the appropriate treatment team and open the patient’s chart.

3. Click on “Order Entry.” Type “transfer patient” into the order box and press enter. Select the “transfer patient” order from the list of options.

4. Complete the required fields and click “Accept.”

5. Click “Sign Orders” to complete the transfer order. There will now be an active order indicating the patient is ready for transfer. Now the patient will need transfer orders waiting for him/her upon arrival to the floor. To do this, follow the directions below.

6. Click on the “Transfer” tab.

7. Click on “Orders Upon Transfer” then “Order Sets.”

8. Complete steps 6-10 from section A.

2. Click on “Rounding.”

3. Follow steps 5-9 in section A.

4. Click “Sign Orders” when complete (rather than “Sign & Hold” because, in this case, the patient has already arrived on the floor).

2. Click “Order Entry.”

3. Enter your order of interest and click “Sign Orders” when complete. These orders will be performed immediately in the E.R. (often within 5-10 minutes of ordering).
Tasks for Patients Already on the Floor
Basic Tasks
F: How Do I Print a Patient List in the Morning?
1. Click on your Patient List tab and select your list of interest.

2. Click on the “Patient Report” tab.

3. Check the “Rounding Report” and/or “MD Patient List” tabs as needed. The Rounding Report is a detailed list including medications, vitals, ins/outs, labs, etc. The MD Patient List, as the name suggests, is simply a list of all patients and their locations.

4. Click “Print.”

called about your patients, can then refer to the Rounding Report beneath for additional information (such as current medications, the “one-liner,” etc).

#1) Use the vitals and Ins/Outs from your printed morning report.

#2) Under “Patient Summary,” use the “VSQ4” to view Q4 hour vitals. If your patient has been in the ICU, you

can use the “VSQ1” tab to view hourly vitals.

#3) Ins/Outs (with detailed descriptions of their sub-components) may be found either in the “Intake/Output” tab

or by clicking on “Patient Summary” and then the “I/O” tab.

- Another option is to click on “Patient Summary” and then “Lab.” This will display all laboratory and culture data in chronologic order over the last 48 hours. This may be useful in the ICU when you have multiple labs constantly returning every several minutes to keep your eye on the most up to date labs.

Alternatively, once you become familiar with the way Epic labels labs, you can type your lab of interest into the “Search” box in the “Results Review” section. For example, to trend a white blood cell count you would type in “WBC.” Some of these labels are not entirely intuitive. For example, if you begin to type in “Sodium,” Epic may default to “Sodium, ISTAT” rather than the true serum sodiums from the lab. You would have to type “Sodium, S” to force it to display “Sodium, Ser/Plas” for true serum sodium results. This may feel awkward at first, but you will quickly get the hang of it.

For studies done several hours to a day prior that do not yet appear in Epic, they may have been dictated but simply not yet transcribed. To listen to radiology patient dictations, dial 57617, then 20#, then medical record number followed by #. Press 8 to skip to the next report.

Of course, for specific questions regarding an imaging study, particularly if it will effect patient care, speak with the radiologist directly.
K: How Do I Write A Progress Note? Procedure Note? Death Note?
1. Click on Notes.

2. Click “New Note.”

3. Click “Cosign Required” and enter the name of your attending.

4. Under “Type,” enter “progress note.” If you are on a consult, you initial note type would be “Consults” and subsequent notes would be “Consult Follow-Up.”

5. Type your note of interest. The use of templates is discussed in the “advanced tasks” portion of this document in section “V.”

6. Click “Accept” to sign your note and save it to the chart.

2. Click on “Notes/Trans.”

3. Click on “Filters.”

4. Click on “Category.”

5. Look through the list for a discharge summary type note. This is usually listed as “D/C Summaries” or “HX-DISCHARGE SUMMARY” depending upon how the user titled the note when entering it in Epic.
M: How Do I Find Specific Items of Interest in the Outpatient Chart?
Tip: You can easily collate the outpatient Epic chart into one large document that can be searched for particular terms of interest.
1. Click on “Chart Review.”

2. Click on “Notes/Trans.”

3. Click on “Select All.”

4. Click on “Review Selected.” After a few seconds, depending on how large the outpatient chart is, the outpatient notes will be chronologically displayed in one large document.

5. Click CTRL-F to search for your term of interest (similarly to searching a Microsoft Word document).
Tip: This is a very powerful tool. You can use it, for example, to find out the last time your patient saw a certain physician, had a colonoscopy, or was admitted with chest pain depending on how you structure your search terms. It is not the most elegant method, but it is the only way to search the outpatient chart at present.
Tip: You can also organize the outpatient chart by filtering the note types. To do this, click on “Chart Review,” then “Notes/Trans,” then “Filters,” then “Category.” In this view, you may easily be able to select various categories of notes, including progress notes, discharge summaries, h&p’s, etc. Similar notes can be filed in a variety of different category names because of Epic’s redundancy (i.e., there are several different ways an H&P can be titled) but this is nevertheless a useful tool to focus your search in the outpatient chart.
N: How Do I Review the Inpatient Medication History?
1. Click on “Patient Summary.”

2. Click on “MedHx.” This will display your patient’s inpatients medications and administration history in various categories, including scheduled meds, completed meds, discontinued meds, continuous infusions, and prn meds.

2. Click on “Meds.”

3. Click on “Filters.”

4. Uncheck the “Current Meds Only” box at the top.

5. In the “Date Range” section at the bottom, select the “From” and “To” dates you would like to filter through and click the magnifying glass when you are done.

You will now see a variety of different medications. By clicking the various filters at the top, you can sort your results by generic drug name, therapeutic class, and even ordering provider.

You may then double click a specific medication and then click on “Full Administration Report” to view further details of the administration history during that hospital stay.
P: How Do I Review Details of Inpatient Pain Medication Use?
1. Click on “Patient Summary.”

2. Click on “Pain.”

3. You will see a graph of the patient’s reported pain levels and a correlating pain medication administration history below. Corresponding vital signs are displayed as well.
Tip: For PCA usage, the best way to determine 24 hour usage is still to speak with the nurse directly. PCA use will be displayed in this view, but at present variability in reporting methods make this view inaccurate. For example, various RNs will chart in volume, concentration, or milligrams. Further, if the RN doesn’t clearly document when the PCA cartridge was changed, it is essentially impossible to determine details of PCA use from Epic alone.
* If you do not see “Pain” under “Patient Summary,” refer to “Adding Additional Tabs to the Patient Summary Screen” in section 1.

Q: How do I Determine Transfusion History Overnight?
Tip: Similar to PCA usage, Epic does not yet have a full-proof way to view this. Your best bet remains speaking with the nurse directly. However, you can use the I/O section to indirectly get an idea of transfusion requirements as described below.
1. Click “Intake/Output.”

2. Under “IN”, expand the “Blood” section. Here you will see a variety of “Transfusion Components.” If you place your mouse over the component and wait a second, a dialogue box will pop up displaying the component type (e.g. prbc, platelets, etc).

By looking at the volume of each individual blood product given, you can indirectly infer how many units they received. In general, pRBCs and platelets will be 200-300 cc/unit, ffp 150-300 cc/unit, and cryoprecipitate 10-15 cc/unit. These volumes are generalized and can have significant variability depending on specific scenarios. However, they are useful to know to get a rough idea of transfusion requirements. If you need specifics regarding overnight transfusions, again, the best way is by speaking to the nurse directly.
Tip: The “Transfusion” report under “Patient Summary” is not useful to accurately document transfusion history. It is a more useful view for nurses to document pre/post transfusion vitals.

Tip: The “TRANSFUSION SVC TESTS” under “Results Review” is also not an accurate way to determine transfusion history. This view reflects crossmatched blood and blood ordered from the bank, but not necessarily blood products transfused to the patient.

2. Click “Diabetes.”

This view will display the diet type, percent consumed, point of care blood sugars (in text and by graph), and insulin administration. Place the curser over a specific insulin administration and wait 1-2 seconds to view additional details (if available).
* If you do not see “Diabetes” under “Patient Summary,” refer to “Adding Additional Tabs to the Patient Summary Screen” in section 1.
S: How Do I Review Antibiotic History?
1. Click “Patient Summary.”

2. Click “Abx.”

This will display a fever curve, wbc curve, cbc trend, and chronologic antibiotic administration history. Click the left arrow at the top to view older data. You can change the view to q8/12/24 hours at the top-right to change the amount of data displayed on your screen at once.
* If you do not see “Abx” under “Patient Summary,” refer to “Adding Additional Tabs to the Patient Summary Screen” in section 1.
T: How Do I Review Orders Placed Overnight?
1. Click “Patient Summary.”

2. Click “OrdHx.” This will display a chronologic view of all orders placed on your patient.

IP INSULIN CONTINUOUS IV INFUSION = insulin drip order set.

IP INSULIN TRANSITION OFF IV INFUSION = transition off insulin drip order set.

IP INSULIN PUMP = insulin pump order set.

IP SUBCUTANEOUS INSULIN SCALE – INITIATION = starting a sliding-scale order set.

IP SUBCUTANEOUS INSULIN SCALE – MAINTENANCE = modifying a sliding-scale order set.

IP PAI PATIENT CONTROLLE ANALGESIA (PCA) = PCA order set.

HEPARIN PROTOCOLS = heparin drip order set.

IP MED COMFORT CARE = comfort care order set.

IP POST PROCEDURE ORDERS LUMBAR PUNCTURE = post-LP order set.

IP POST PROCEDURE ORDERS PARACENTESIS = post-paracentesis order set.

IP POST PROCEDURE ORDERS ARTHROCENTESIS = post-arthrocentesis order set.

IP POST PROCEDURE ORDERS THORACENTESIS = post-thoracentesis order set.
V: How Do I Create My Own Templates? How Do I Borrow Those of Others?
Tip: View the Epic Tip Sheet for greater detail regarding making progress note templates.
Tip: Epic allows you to create a “smart phrase” which is a template created by you. It can be as brief as a single word or as long as entire progress note template. Whenever you are typing a note, you may enter “.phrase” where “phrase” is the name of your smart phrase to automatically insert it into your note. The creation of a smart phrase is described below.
1. Click on “Tools.”

2. Click on “SmartTool Editors.”

3. Click on “My SmartPhrases.” This will open a “Workbench” tab.

4. Click “New.”

5. Type in the name of your SmartPhrase.

6. Type the text of your SmartPhrase

7. Click “Accept” when you are finished. Your smart-phrase is now created.
Tip: You can borrow smart phrases that have been created by your peers as well. Within the workbench, click “Open.” In the “User” field, type in the name of the person’s smart phrases you wish to view. Click “Load User Phrase List.” That person’s smart phrases will now appear. You can click “Share” and add yourself to the list of users with whom to share the smart phrase to make it easily accessible for yourself as a “dot phrase.”
Tip: You do not need to spend time figuring out fancy ways to display labs and vitals in your progress note. People will generally refer to the Epic chart directly for these details. Focus on succinctly describing details of patient care in your note. This will also increase the liklihood that people will actually read your work.
Discharging Patients
W: How Do I Discharge My Patient Home?
1. Click on the “Discharge” tab.

2. Click the “PTA Med Document.” This list should accurately reflect the patient’s prior to admission (pta) medications. This should be reconciled PRIOR to completing discharge orders.

If you need to edit some of your signed discharge orders, simply click on the “Discharge” tab and then “Discharge Report.” You will find links to edit and remove various orders as you scroll down.

Once your AVS looks right, you are all done with your discharge!
X: How Do I Discharge My Patient To A Skilled Nursing Facility (SNF)?
1. Follow the same instructions as above in section “W.” However, instead of using the “IP GENERAL DISCHARGE ORDER SET” use “IP INTERAGENCY DISCHARGE ORDERS.”
Tip: For discharge medications, you may select “No Print” as the SNF will directly administer the medications. Be sure to review the AVS, though, as the SNF will administer medications based on these orders!

Tip: In the interagency order set, you have the opportunity to place pt/ot referrals, refer for a home health aid or home nursing, order labs at the nursing home, and order home oxygen (under the “Respiratory” section of the order set; you must specify the route and flow rate; you must also document that the patient requires home oxygen either by pulse oximetry or blood gas either here or in your progress note).

2. Click “New Note.”

3. Click “Cosign Required” and enter your attending’s name.

4. In the “Type” section, enter “D/C Summaries.”

5. Type your discharge summary. You may do this free-hand, use one of your own templates, or use one of the pre-existing templates. For the latter, click on the icon with the three boxes (in between the plus sign and left arrow on the toolbar) and enter “IP GEN DISCHARGE SUMMARY.” You can press F2 to toggle to the next field if you choose to use the pre-existing template.

6. Click “Accept” when you have completed your note.

#2) If your patient was discharged within 72 hours, click on “Patient Lists,” expand “Recently Discharged,”

expand “Recently Discharged,” click the appropriate time-frame and select your patient from the alphabetically

sorted list. Double-clicking their name will open their chart in the “inpatient environment” with the familiar view,

allowing you to enter a discharge summary in the notes tab.

#3) If your patient was discharged more than 72 hours ago, you can still type a discharge summary by following

these steps. Click on “Pt Station” at the top. Enter the patient’s name or mrn and click “Find Patient.” Scroll

through the top list and click on “Admission” that reflects your patient’s recent admission. Then click “Open