The A-Z’s of Epic: A Housestaff Survival Guide
By Rondeep Brar, MD (Class of 2010)
Foreword: Welcome to the A-Z’s of Epic: A Housestaff Survival Guide! I hope this document proves to be useful. It is not meant to be all-inclusive but rather to provide assistance in efficiently performing basic and advanced Epic tasks for the average medicine housestaff crunched for time.
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 firstname.lastname@example.org.
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 ” or “GENERAL MEDICINE SPLTY .” These settings are your “login context.” Depending on which login context you use, Epic will personalize your display and the options available to you.
Tip: For practical purposes, you should use either “MEDICINE SPLTY” or “GENERAL MEICINE SPLTY” at all times except when working in the Emergency Room, at which time you should use the “EMERGENCY DEPARTMENT” login context.
Tip: If you would like to change your login context while in Epic, you do not need to log out and log back in. Rather, click on “Desktop” (top-left) and then “Change Login Context.”
Logging Out Tip: When you are ready to log out, do NOT click the “X” in the top-right hand corner. This will shut Epic down completely and force the next user to re-load the software (which is time-consuming).
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.
Patient Lists Tip: The ability to create multiple patient lists is a strong point of Epic. You can create separate lists for your ward patients, cross-cover patients, patients who need cultures followed, interesting patients (to present, follow, or write case-reports), the ER, ICU, etc. This can dramatically improve your efficiency when covering dozens of patients on multiple floors and services (i.e., when you are on call or night float).
Tip: By using Epic’s built in “System Lists,” your personal lists will automatically refresh themselves as patient’s are admitted, discharged, and transferred to other floors.
Creating a Patient List 1. After logging in, you will be brought to 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.
Tip: When Epic loads and you select “Patient Lists” to review your patients, you can designate a default list to display first (i.e., of your multiple lists, suppose you would like Epic to display your “Wards” list by default). To do this, place the mouse over your list of choice, right click, and select “Default List.”
Adding Patients to Your List Let’s assume you are intern A on Stanford Wards team 1. You have created a list called “My Ward Patients” using the above directions. Now you would like to add your patients to this list.
1. Click on “Patient Lists” and expand the folder titled “System Lists” by clicking on the “+” sign. You will now see the variety of system lists handled by Epic.
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.
In our example, you would click on “Med Univ 1A,” keep the mouse button held down, and drag this list up into your personal “My Ward Patients” list.
Your personal list will now display all patients assigned to “Med Univ 1A.”
Tip: The following are useful team designations to know under “MD Primary Team”: Stanford Wards = “Med Univ” (teams 1-4), PAMF Wards = “Med PAMF” (teams 1-4), Team T = “Med Tx-Hep”, Cardiology = “Cardiology” (teams 5a-6b), ICU = “MICU” (teams green and blue), Oncology = “Oncology,” and Hematology = “Hematology.”
Assigning Yourself to the Treatment Team In order for Epic to know what patients belong to “Med Univ 1A” in our example, that intern must assign him/herself to the “Treatment Team.” Epic keeps track of which patients are placed on which System List using this “treatment team” designation.
To assign a treatment team, you first need to locate the patient in the hospital. Your patient will likely be in either the Emergency Room (ER), Clinical Decision Area (CDA; the observation unit of the ER), or on a certain floor of the hospital.
1. Consider the example of locating a patient in the ER. Under “Patient Lists,” expand “System Lists,” and then expand “Emergency Department.” Click on the list titled “Emergency Department” to display all the patient’s in the ER. For some odd reason, Epic displays this list in reverse order so that it may appear blank. To correct this, click on the “Bed” column of the patient list to organize the patients by their bed number in the ER.
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.”
Once this is done, your patient will now appear under the “MED UNIV 1A” Epic System List. Since this is the list you have placed in your personal “My Ward Patients” list, the patient will now appear on your personal list as well.
Tip: To remove a patient from the system list, right click on the patient, select treatment team, highlight the team of interest (TT MED UNIV 1A in our example), and click “Terminate.”
Tip: When admitting a patient and entering the Treatment Team, you should enter your name, your resident’s name, and your attending’s name. For yourself, place your name (last, first) in the “Treatment Provider” section and write “Primary Intern” in the “Relationship” box. Repeat this for your resident and attending, using “Primary Resident” and “Primary Attending,” respectively, for the “relationship” box.
Tip: These treatment teams not only help Epic organize all patients within the hospital, but also help nurses decide which physician to page. Keeping it up to date can save you many unnecessary pages.
Adding Additional Tabs to the “Patient Summary” Screen Tip: Throughout this document, we will be referring to various tabs under the “Patient Summary” screen. Depending on how your Epic account is set up, some of these tabs may not be available to you. To add a tab, follow the instructions below.
1. Click on “Patient Summary.”
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.”
Patient Summary: A data-rich section in which you can locate vital signs, recent labs/cultures/imaging, antibiotic history, narcotic use, insulin use, a chronologic history of orders placed for your patient, a full medication administration record (MAR), and a list of current indwelling lines/catheters and their dates of placement.
Chart Review: The equivalent of the “outpatient chart.” Useful for prior clinic notes, prior discharge summaries, prior colonoscopies, etc. In reality, all inpatient notes get filed under “Chart Review” as well. However, inpatient notes are much more easily viewed under the “Notes” tab in the patient chart.
Results Review: All laboratory, imaging, and culture data may be found here.
Intake/Output: Reviews daily fluids ins/outs as well as their sub-components (i.e., po, iv, urine, stool, drain output, etc).
Synopsis: Not of utility.
Allergies: Here you can review and add to a patient’s allergies. Allergies are also displayed near the top-right of any patient’s chart (above “Attending.”)
Problem List: Currently a matter of debate regarding whether housestaff are responsible for updating this section prior to discharge. In general, if a major diagnosis, such as thyroid cancer, is missing from the patient’s automated problem list, it probably should be added here. For less severe problems, such as GERD, updating this list will probably not be feasible given your time constraints.
History: Also a section you typically do not need to use in the inpatient setting. If you feel compelled to add something to a patient’s past medical history that is not part of the Epic record, however, you can do it here.
Imm/Injections: Immunization history for the admission may be reviewed here. A rarely used tab.
Notes: Contains all inpatient progress notes, including those from attendings, fellows, residents, interns, medical students, speech therapists, occupational therapists, nurses, case managers, dietitians, etc. By default, it will display notes in reverse-chronologic order (most recent note first). You can click on any of the column-headings, such as “author” or “category” to change the way in which the notes are sorted. You can view specific note types, such as h&p’s or progress notes using the tabs at the top.
A few things to keep in mind: The “filed time” is when the note was electronically signed and the “note time” is the time the note was started. Additionally, anytime you addend a signed note or an attending co-signs your note, the “filed time” gets updated and that note goes to the top of the chart. Keep this in mind when reviewing the chart.
Consider the following example: You request a hematology consult on 11/2. The fellow writes a note that day and it appears in the Epic chart. The next day (11/3) the hematology fellow writes another note. The hematology attending reviews notes awaiting his signature and co-signs the 11/2 note but not the 11/3 one. This will place the 11/2 note above the 11/3 by their “filed time.” Be weary of this. Another common scenario is to suddenly see multiple progress notes by one attending in the chart. For example, if the hematology attending co-signs all notes from 11/2-11/7 in a single sitting on 11/7, they will populate the 6 most recent notes in the chart. Hence, always be sure to compare the “filed time” and “note time” to make sure you are viewing the most recent recommendations.
Tip: Depending on the way an attending co-signs your notes, your notes may get re-named with your attending appearing as the author. Your original note (with your name attached) is always preserved, however, in a blue hyper-link at the bottom of the note.
Order Entry: The most useful and quickest place to enter orders. Unfortunately, not all order entries are entirely intuitive. For example, in replacing 40 meq of iv potassium, one would order 10 meq per hour and administer for “4” hours. Similarly, to provide a liter of saline, you may order saline at 200 cc/hour for 5 hours or 100 cc/hour for 10 hours. To explore and change the variety of details for an order (dose, frequency, start time, stop time, etc), simply click on the blue hyperlink for each order before clicking “Sign Orders.”
Rounding: There are several useful things to do here. The “PTA Med Document” contains the “prior to admission” medications that should be reconciled prior to discharge (more on this later).
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”).
Consult: No need to use this tab.
Transfer: Used to direct the transfer of patients out of the ICU.
Discharge: Used to discharge patients from the hospital.
Now let’s move on to performing specific tasks within Epic.
Section 3: Performing Specific Tasks Tasks Prior to Patient Arrival to Floor A: How Do I Admit a Patient from the Emergency Room? 1. Locate the patient in the Emergency Room and assign the appropriate treatment team (including team, intern, resident, and attending). If you are unsure how to do this, refer to the “Getting Started” section above.
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 2nd 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.
D: How Do I Admit a Patient Who is Scheduled for a “Direct Admission?” Tip: Occasionally a patient will be “directly admitted” from the Cancer Center, home, or one of the specialty clinics. Direct admission refers to a patient arriving immediately to the floor without having to go through the E.R. first. For these patients, you cannot place “Signed and Held” orders ahead of time. You must wait for them to arrive to the floor (which creates an electronic inpatient chart) and then you may enter their admission orders.
1. Locate the patient of interest and open their chart.
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).
E: How Do I Place Orders for E.R. Patients to Happen Immediately? Tip: You can place active/immediate orders for patients you will be admitting from the E.R. Since it may be several hours (in rare cases even >24 hours) before they arrive on the floor and activate your Signed/Held orders, it may be helpful to order various labs/imaging (i.e., blood cultures, troponin, lactate, abdominal ct, etc) while they are in the E.R. to expedite your workup.
1. Locate the patient in the E.R. and open their chart.
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.”
Tip: Most interns print both the Rounding Report and MD Patient List at the same time. For signout, it is helpful to place the MD Patient List on top of the Rounding Report. The “to do” list can be listed cleanly on the MD Patient List (since this is often only one or two pages). The night-float intern, when carrying out the “to do” list or getting
called about your patients, can then refer to the Rounding Report beneath for additional information (such as current medications, the “one-liner,” etc).
Tip: There is often a lag of 30 seconds to 2-3 minutes before your list will arrive at your selected printer. Don’t repeatedly print your list if it doesn’t immediately arrive, or you will soon be printing out multiple lists on accident.
Tip: For most locations in the hospital, Epic has automatically selected the closest printer as its default. If it does not appear, try to locate the printer # (usually a label taped on the printer itself) and enter “PRINTER####” in the “Printer name” section where #### refers to the printer #.
G: How Do I Review Details of Vitals and Ins/Outs Overnight? There are several ways to do this. Some options include:
#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.
Tip: You may notice your rounding report notes a maximum temperature that does not clearly appear under the vitals you see under “VSQ4.” Because of the way Epic deals with data entry timing, some of this data may not appear in this view. If you switch to “VSQ1” (even for a regular floor patient), you will often see additional data that does not appear in VSQ4. Hence, it is useful to use the rounding report for a quick glance to see if your patient has been febrile overnight, and then to refer to “VSQ1” for specific details if needed.
H: How Do I Review Lab Results? - One option is to click on the “Results Review” tab. By clicking on each of the individual categories, you will see chronologic lab results for a specific category (e.g., “Hematology” for CBCs, “Coagulation,” for coags and dic panels, “Chemistry” for metabolic panels and LFTs, etc).
- 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.
Tip: The default view for “Results Review” is to place most recent labs to the far right. Some people find this visually difficult to line up with the appropriate labels in the left hand column. You can reverse the way Epic displays these labs. Click on “Results Review,” then “Options,” and then check the box labeled “Trend Dates in reverse chronologic order.”
Tip: You can easily trend and graph labs in Epic. To trend, click on “Results Review” and then expand the laboratory list to locate your lab of interest. The data trend will be displayed in the results section. For example, to trend a serum sodium, you would expand “Chemistry,” then “General Chemistry,” then click on “Sodium, Ser/Plas.” Once the trend is displayed, you can click on the lab name (“Sodium, Ser/Plas” in this example) and then “Graph” to visually plot the data.
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.
I: How Do I View Culture Results? 1. Click on “Results Review” then click on (don’t expand) “Microbiology.” This will chronologically display culture data. Abnormal culture results are marked with a red exclamation point. To view details of a specific culture, double click the notepad icon.
Tip: Cultures under this section CAN be positive without a red exclamation point. This has to do with the way the microbiology lab currently flags cultures. For example, blood cultures may have 4/4 bottles with gram positive cocci in clusters that have not yet been speciated. Initially, you will see this data if you double click the notepad, but it may not initially be labeled with a red exclamation point. Hence, you CANNOT rely on this tag to quickly screen whether or not your patient has positive cultures.
Tip: To avoid the above pitfall, you can click on “Patient Summary” and then “Micro.” This will chronologically display culture data as well as its results in a screen you can quickly scroll through (saving you the time of double-clicking each notepad in the “Results Review” section). However, if a culture is positive, this view typically will not display sensitivities. For this, you will need to return to the “Results Review” section a double-click the culture of interest under “Microbiology.”
J: How Do I Review Imaging Results? 1. Click on “Results Review.” Expand “Radiology” to view all dictated and transcribed imaging results.
Tip: When you double-click the notepad icon to read the report of an imaging study, there is a link at the top stating “View Full Radiology Images – Patient Level.” Clicking this link will automatically open Centricity and load the image of interest.
Tip: Often times on call, you will want to discuss imaging results with a radiologist. They are often extremely busy and will often place a quick review of the study in Centricity to avoid multiple phone calls. Always check here first before calling the radiologist. To look for this preliminary interpretation (often done within minutes for studies done in the E.R.), click on the “Exam Notes” tab in Centricity.
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.
Tip: If you wish to save your note but not yet sign it, click “Pend.” When you wish to resume your note, click on “Notes” and then scroll to the right to reveal the “Pended” tab. Click on your note and then click “Edit Note” to resume your work.
Tip: There is no need to type a brand new note each day when you plan to re-use some of the prior notes’ components. Simply click on your last note, then click “Copy” in the top-right corner. This will open up a new note, automatically copy in your previous note’s text, and refresh the labs, vitals, and ins/outs.
Tip: These steps are the same used to write any note type, other than changing the label of the note under “Type.”
Tip: For procedure notes, list “Procedures” as the note type. When typing the note, click on the icon with the three boxes at the top (between the plus sign and left arrow on the toolbar). This will allow you to select from pre-existing note templates. Type in “IP PROC” and you will see a variety of procedure note templates, including those for arterial lines, arthrocentesis, central line placement, central line exchange, lumbar puncture, paracentesis, and thoracentesis. Select your note of interest by double-clicking. Edit it as you see fit. Press F2 to toggle between text fields. Click “Accept” when you are finished.
Tip: For death notes, list “D/C Summaries” as the note type. The note template for this is “IP DEATH CERTIFICATE WORKSHEET.” Note that this worksheet requires you to list the name of the ctdn (california transplant donor network) representative you spoke with as well as a reference number (they will provide both of these to you at the end of your phone call). For a deceased patient, you need to write two notes. One should be this death certificate worksheet. The other should be an actual, brief discharge summary. Both are labeled as “D/C Summaries” for the note type.
Advanced Tasks L: How Do I Review the Last Discharge Summary? 1. Click on “Chart Review.”
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.
Tip: Green means a medication was given and red means it was not. You can click on any particular green or red time to find out more details about that specific administration. You can also click on the medication itself, then “Full Administration Report” to view the entire administration history of that medication for the current admission.
O: How Do I Know if my Patient Ever Received a Certain Medication? Tip: Sometimes it is helpful to know whether your patient has received a certain medication at Stanford (e.g. heparin in a patient who is thrombocytopenic, morphine in a patient with a “morphine allergy,” etc). If your patient is not a great historian, the steps below might bring you to a quicker answer.
1. Click on “Chart Review.”
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.
R: How Do I Review Insulin Usage and Blood Sugars? 1. Click “Patient Summary.”
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.
Tip: When you can’t find your fellow housestaff for signout, this is an easy way to get a quick idea of what happened overnight.
U: Which Types of Common Tasks Require the Use of Order Sets? Tip: Order Sets in Epic are used for orders that come in a bundle. For sliding scale insulin, for example, the order set contains not only the insulin, but the nursing orders for fingersticks and a hypoglycemia protocol as well. Order sets can be accessed by clicking on “Rounding” then “Order Sets” and then by typing in your Order Set of interest. Click “Open Order Sets,” complete the orders of interest, and then click “Sign Orders” to activate them. Below are examples of common order sets.
IP INSULIN – DIABETIC KETOACIDOSIS = DKA order set.
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.
These medications are initially inputted by the nurses. However, often times the medication, dose, or frequency is actually incorrect.
Review the list. For pta meds that are inaccurate, click them, and then click “Discontinue Med.” If this was a medication they actually weren’t taking, or if the dose or frequency is incorrect, enter “Error” under “Discontinue reason.” After you re-enter the correct medications, this will prevent your discharge instructions from telling the patient to both start and stop taking the same medication (which has long been a source of confusion in Epic).
Add additional medications to the pta med list as needed. Epic has a variety of names for various medications that can quickly become confusing. For PO tabs, the easiest input format for “Medication Name” is “#### PO,” where #### refers to the medication name. For example, if one were to enter tylenol in the “Medication Name” section, Epic will generate dozens of confusing tylenol formulations to choose from. If one simply enters “tylenol PO,” the first choice is a generic “tylenol PO.” For each pta medication you add, fill in the dose, route, and frequency (the remaining fields may be left blank).
After this list accurately reflects the patients medications prior to admission, you have officially reconciled the pta meds.
3. Now be sure the patient’s pharmacy is correct in Epic if you plan on faxing prescriptions. Click “Orders” (while still in the Discharge navigator). At the top, you will either see a pharmacy name (e.g., “Safeway) in blue or the words “No Selected Pharmacy.” Click on this text and either verify the pharmacy is correct or enter a new pharmacy if needed (use the built in search tool to find a pharmacy based on name, address, or phone #).
4. Now that you have reconciled pta meds and chosen the correct pharmacy, you can place your discharge orders. Under the discharge tab, click “Order Sets” and open the order set titled “IP GENERAL DISCHARGE ORDER SET.”
Complete the order set. This involves basic orders (discharge patient, diet, follow-up), review of pta meds, and review of inpatient meds (giving you the opportunity to prescribe them if you so choose).
If you have discontinued pta meds that were entered in error, click on “No Change” when asked to review them as part of the order set.
If you would like to order additional discharge medications, enter them in the order box under the blue bar with “Additional Discharge Orders.” After entering the medication, you can click on it to edit the dose, frequency, amount prescribed, and number of refills. If you wish to fax the medication, be sure the “Fax” box is checked. If you will print it, click “Print RX.” If you would like to neither fax nor print the new medication, click the “No Print” box when you are entering the medication details. Note that discharge prescriptions will print AT THE PATIENT’S FLOOR (not where you are sitting). So, if you are discharging someone on C3 and you are on D-Ground, your prescriptions will be waiting for you on C3.
If you would like to place referrals, you may also enter them in the “Additional Discharge Orders” box in the format of “refer ####,” where #### refers to the specialty you are referring to.
If you would like to order follow-up imaging (e.g., a chest ct in 3 months), you may also enter this in the “Additional Discharge Orders” box.
After you have completed the order set and entered your additional medications, imaging, and referrals, click “Sign Orders.”
5. To verify all your hard work is accurately reflected, click on the “Discharge” tab and then click on “Preview AVS.” This is the document the patient is given prior to discharge and should reflect all your major discharge orders (activity, diet, follow-up, medication reconciliation, new medications, follow-up imaging, referrals, etc). Basically, all your discharge orders will be found on this document.
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).
Tip: If you are discharging a patient home but need to set up home oxygen, complete your discharge orders as described in section “W.” Then open the interagency order set and fill out the request for oxygen under the “Respiratory” section.
Tip: If you are discharging a patient home with home antibiotics, complete your discharge as described in section “W.” Enter the antibiotics as “Additional Discharge Orders.” Then open the interagency order set and be sure to place referrals to home nursing if needed. Speak with your case manager if you have questions.
Tip: If the patient needs a discharge device such as crutches or a hospital bed, complete your discharge as described in section W.” Then open the interagency order set as above and enter your request in the “DME” section under “DME Discharge Order.” DME refers to durable medical equipment. Again, speak with your case manager if you have questions regarding this process.
Y: How Do I Write My Discharge Summary? 1. Many people choose to dictate discharge summaries. If you choose to write one, click on “Notes.”
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.
Z: How Do I Write a Discharge Summary for a Patient That Was Discharged a Few Days Ago? In this case you have three options:
#1) Dictate the discharge summary.
#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
Chart.” This will also open the chart in the familiar inpatient environment and allow you to enter a discharge