2) For any patient related encounter, where you personally speak to a patient, you MUST log the details in Epic as a telephone encounter:
- Go to the Epic button on the upper left hand corner of the screen
- Select “Patient Care” → Telephone Encounter
- Enter Patient’s Name or MRN and “Accept”
- Document the reason for call ("Follow Up" is generally fine) and, if you choose, the number (s) and time (s) you called.
- Write a brief note.
How do I create a patient encounter in epic?
1. Click on the ‘Epic’ button in the upper left corner of the Epic screen. 2. Hover over ‘Patient Care’ sub-menu. 3. Select ‘Encounter’. 4. Patient look up box will populate, then 5. Enter patient name, or MRN. 6. Select ‘New’ encounter. 7.
How do I view patient scans in epic?
to go-live (4/28/18) within Epic •Look up patient record and open chart •Select the Chart Review activity tab •Click the Media tab of Chart Review •Click Patient Scans button
How do you record a call with a patient?
1 Record the content of the call in the patient’s record 2 Include any instructions provided and the patient’s understanding of that information 3 Include your name—or the name of the staff member who took the call—and information about the patient’s requests, concerns and issues More items...
Does epic support point-and-click documentation?
In addition to being able to populate the content of your note using free-text, SmartPhrases, SmartText, SmartLists, and voice transcription, Epic also includes a NoteWriter tool that allows point-and-click documentation.
What is EMR billing?
How to make a problem list editable?
Can you send a patient reminder to Epic?
About this website
How do you document a phone call with a patient?
Be specific.Record the content of the call in the patient's record.Include any instructions provided and the patient's understanding of that information.Include your name—or the name of the staff member who took the call—and information about the patient's requests, concerns and issues.More items...•
How do I create a documentation only encounter in epic?
To create a new Documentation Only encounter, there are a couple of options to do this. From the Epic menu button, click on Patient Care and then select Encounter. Or you can search for a patient through the Patient Lookup function and then select NEW after choosing the patient.
What is a telephone encounter?
What is a telephone encounter and when do I use it? o Telephone encounters are used when you make an outgoing or receive an incoming telephone call from the patient and want to document that communication o To complete this type of visit: o Select the Telephone Call button on your main toolbar.
What is an encounter in epic?
Encounter= A clinical contact. For example, an office visit, an admission, or a telephone encounter. Even if more than one evaluation or procedure takes place at a visit, it is still usually considered one encounter.
How do you document in epic?
Uploading Documents into EpicSave the file as a PDF to your desktop or another folder.Log into Epic in the EHHOP department.Click the Epic button in the top left, select "Patient Care" > "Media Manager" from the drop-down, and select the patient for which you'd like to upload media. ... Select "Import".More items...
How do you enter an epic encounter?
Search for Patient and locate Encounter of Interest 1. Click on Patient Station in the Epic Toolbar at the top of your screen. 2. Enter the information you have that identifies the patient uniquely such as the MRN or name and date of birth.
What are some examples of telephone conversation?
Telephone Conversation ExamplesReceptionist: “Good morning, High tech industries, Emily speaking. ... Client: “Good day to you, I am calling to speak with Mr. ... Receptionist: “I am afraid that Mr. ... Client: “This is Mr. ... Receptionist: “Thank you, Mr. ... Client: “No, thank you. ... Receptionist: “Of course, that won't be a problem.More items...
Where can you access the telephone encounter activity in epic?
Go to Epic>Patient Care>Click Telephone Call OR click Telephone Call from the Epic Toolbar.
What is a good telephone conversation in a clinical setting?
Listen carefully and allow the caller both the time and opportunity to ask questions. Speak to patients clearly and slowly, and enunciate carefully. Use easy-to-understand language that avoids medical terminology. Obtain the services of an interpreter if you encounter a language difficulty.
Is Epic an EHR or EMR?
Epic EHR is a cloud-based EHR with more than 250 million electronic records of patients. As an electronic medical record (EMR), it contains a patient's medical history, diagnoses, medications, immunization dates and allergies, but it also digitizes patient health information, which is a main characteristic of EHRs.
How do you do an erroneous encounter in epic?
Remove existing Reason for Visit [Chief Complaint] in the Visit Info. section of the Rooming tab. Add “Erroneous Encounter [ERROR]” and click Sign Encounter.
How do I quickly chart in epic?
5 tips to chart faster in EpicIllness HPI form. Use the “Illness” template in Epic. ... Dictate, dictate, dictate (real time) If you have the ability to dictate, dictate. ... Minimize your dot phrases. ... Use floating windows. ... Make sure all of your “wrenches” are optimized!
How do you change encounter type on Epic?
Navigate to the signed encounter in the patient's chart. ... Click Edit next to the Encounter type header in the Addenda pane (see Graphic 2). ... Select the new code from the Encounter type drop-down (see Graphic 3). ... Add any additional comments in the Addendum Notes field and then press Accept (see Graphic 4).More items...
How do you document an erroneous encounter in epic?
Remove existing Reason for Visit [Chief Complaint] in the Visit Info. section of the Rooming tab. Add “Erroneous Encounter [ERROR]” and click Sign Encounter.
How do I delete an epic document encounter?
Press the Actions button in the upper right-hand side of the encounter and select Delete encounter from the drop-down menu (See Graphic 1). 2. Press the Delete button on the Delete encounter confirmation modal (see Graphic 2).
How do you close an encounter on Epic?
Closing an Encounter: In order for an attending to close an encounter, he/she MUST DO THE FOLLOWING:Enter a Reason for Visit (should really be done by the clinician team)Enter a Diagnosis (should also be done by the clinician team)MUST Sign ALL Orders.Enter a Level Of Service (can only be done by the attending)More items...
EPIC documentation check list - General Nursing, Support, Stories ...
I don't know about Epic, but Cerner is so non-intuitive it begs for end-user failure. I don't know just whom is making millions off this crappy software buried under pages of bad code-writing added onto more layers of lazy, bad code-writing ad infinitum, but they should be shot in the head on the island they're currently retired to, whilst sipping their martinis and Pina Coladas.
EPIC, documentation & time management advice - allnurses
Agree! We use EPIC and one of the more seasoned nurses I work with always complains that her assessments take her forever. Well when I follow after her and see that she's charting respiratory as WDLw/ clear lungs sounds, peri neuro as WDL with +2 pedal & radial pulses, regular apical & radial pulses, etc. and so on, it's no wonder.
EPIC EMR: tricks and tips for hospitalists - Hospitalist X
Sorting out notes section: When you click on the wrench to the far right in Notes section, you can see different options. If you click on Note list layout settings and click on Service instead of Author Name, the notes section will display notes with Specialty name prominently instead of the person’s name.This helps to quickly look for different specialty notes as sometimes we may not ...
Epic Templates | Inova
Inova offers Epic templates for you to document with optimal efficiency These templates have been developed by practicing Inova physicians, and approved by coding, billing and compliance
5 tips to chart faster in Epic - iMedicalApps
5 tips to help you finish your patients chart faster in Epic. These tips are based on lectures I give to residents on charting efficiency.
What is EMR billing?
The EMR is designed to optimize billing by making it easy to include many elements in documentation. However, this has fostered the idea that “more it better”, leading to the note bloat phenomenon in which notes frequently contain redundant, contradictory, superfluous, and/or out of date information.
How to make a problem list editable?
Right click on the imported problem list and “make editable” (Note: you can do this with any element in the note – use this functionality to remove things that may be irrelevant while keeping things you want)
Can you send a patient reminder to Epic?
If you feel you need to follow up on something in the future, you can make a patient reminder for yourself which can be delivered at future time. ( see tip sheet) Results can be sent to patients as Epic patient message or in a short letter (which you can route to your administrative assistant for mailing).
How to call a patient on Epic?from ehhapp.org
Click on the red Epic button on the top left of the screen → Patient Care → Telephone Call → Enter in the patient’s name or MRN
What to do if a patient leaves a message on their phone?from magmutual.com
Leaving a Message for a Patient—Be sure that the patient has agreed to receive potential private health information inquiries via a given modality before leaving a message via that modality. Phone messages left by medical staff should just include a name and a request for a callback. Unless specifically authorized by the patient, you should not leave clinical information or medical advice on an answering machine or voicemail. Always document that a message was left for a patient in his or her medical records and have a follow-up system in place to make sure proper contact has been made with a patient. Physicians should never assume that because a message was left, that the patient received it.
What are the requirements for a medical record?from magmutual.com
All telephone communication, either during or after office hours, should be documented in the medical record or telephone logbook when one of the following occurs: 1 Prescribing or changing medication 2 Making a diagnosis 3 Directing treatment 4 Directing a patient to another provider or facility It is important to include the date and time of the phone conversation.
What is a telephone message slip?from magmutual.com
A telephone message slip with the documented advice and decisions reached should be securely attached to the medical record. One source of potential provider-patient conflict is that of a phone call made by a patient with the claim that the call was not returned by the provider. A simple log of all incoming phone calls kept in a chronological fashion may help to resolve this source of conflict. Should a patient then indicate that a phone call was made on a particular day, the call can be confirmed by referring to the log. Be aware that if a separate logbook is used to record phone calls, it should be retained securely in the same fashion as a medical record.
What is telephone triage?from magmutual.com
Telephone Triage—In these situations, physicians face the challenge of making an assessment based on verbal cues instead of being able to observe patients in-person. If a patient is not able to provide an accurate description of symptoms, guidelines should clearly define when a patient should come into the office or be referred to another provider. Only medical professionals with the appropriate training should provide telephone assessments. If a patient seems overly anxious or unsatisfied with the telephone conversation, a face-to-face encounter should be recommended. The timing of and the acuity of that encounter, whether it be in the office, at an urgent care facility, or at the emergency department; all depend on the potential severity of the possible underlying diagnosis. And in situations where patients are told to dial 911 immediately, but are unable to, keep the patient on the phone until another staff member can dial 911 on a separate line.
Why is it important to develop clear procedures for handling telephone encounters with patients?from magmutual.com
Developing clear and definitive procedures for handling telephone encounters with patients is critical to managing risk . Once these procedures are established, all medical and office staff should be properly trained on them and have a solid understanding as to their roles and responsibilities. New office staff should be oriented to these procedures, existing staff should review them, and office managers should consider revisiting how these procedures are used in actual practice to ensure that they are being followed properly. Procedures should address the following:
What are the guidelines for follow up?from magmutual.com
Guidelines for follow-up—Always inform patients of when they can expect a return phone call and make sure that internal tracking systems are aligned so that patients receive follow-up calls accordingly for specific situations such as providing test results or handling prescription requests.
What is call documentation?
Call documentation is an essential opportunity to document communications with patients, leading to more complete and accurate clinical records. ( See related article .)
How to be proactive regarding call documentation?
Be proactive regarding call documentation by developing a policy and corresponding procedures.
Do you have to document a patient's phone call?
You take the time to carefully document patient visits; make sure to take that same care to document patient phone calls. Like other documentation, the common rule when it comes to telephone call documentation is that if it is not documented, it did not happen. Therefore, every clinically relevant telephone call should be documented.
What are the complaints that doctors have about patients?from verywellhealth.com
Complaints doctors have about patients include everything from non-adherence to obnoxious behavior to missed appointments. When the complaints about one patient are just too much, a doctor may choose to terminate their relationship with that patient for any of those reasons, and for others, too.
What to do if your doctor dismisses you?from verywellhealth.com
If your doctor fires you, you have a few options: If you want to go back to that doctor, you may want to attempt to repair the relationship with your doctor. This will involve knowing what the reason was that you were dismissed (which may, or may not, be apparent).
Why are healthcare providers firing patients?from verywellhealth.com
A relatively new reason for dismissal seems to be based on the type of insurance a patient has. In recent years, patients report their healthcare providers are firing them for no apparent reason (at least they are not told what the reason is). The one thing these patients have in common is that their payers are those that reimburse providers at very low rates.
What is the dismissal protocol for a patient?from verywellhealth.com
However, in most cases, the dismissal protocol is based more on ethics and responsibility to the patient than what the law may or may not tell them they must do. These guidelines are mostly intended to keep the healthcare provider out of hot water (at least) or to help avoid a lawsuit.
What does it mean when a patient doesn't show up for an appointment?from verywellhealth.com
From the provider's perspective, that means a window of no income in addition to the fact that the patient isn't getting the help they need.
What to do if you are dismissed from healthcare?from verywellhealth.com
If you want to go back to that healthcare provider, you may want to attempt to repair the relationship with your healthcare provider. This will involve knowing what the reason was that you were dismissed (which may, or may not, be apparent).
What does it mean when a doctor closes their practice?from verywellhealth.com
If the doctor's practice is closing: Just like the rest of us, doctors close their practices. They may sell them, or retire from practice, they may die, or just close their doors.
What is EpicCare inpatient?from quizlet.com
EpicCare Inpatient (ClinDoc) EpicCare Inpatient, also known as ClinDoc is much like EpicCare Ambulatory, except that the clinical tasks are done in the hospital on admitted patients. This includes clinical notes, orders, medication administration, patient monitoring, and discharge orders. Epic Beacon Oncology.
What is Epic remote client?from quizlet.com
Also known as Dorothy (from The Wizard of Oz) this is the module used in a home health setting, in which visiting caregivers (Nurse, Nurse Aides, PT, OT, etc) document care done in a patient's home. Clinicians use a version of Epic called remote client that is installed on their local laptops. This program allows them to document in settings where they might not have any internet connection. Then after they finish their work, they can reconnect to their organization's network and perform a sync that uploads their documentation to the main Epic servers.
What is a lab system in Epic?from quizlet.com
laboratory system for a hospital lab. Orders that are placed either in other parts of Epic or in an external system are transmitted to Beaker via an HL7 Interface1 for processing. When patients arrive to have their blood drawn, the results are entered into Beaker, which then get transmitted back to the ordering doctor.
What is MyChart bedside?from quizlet.com
Where MyChart is focused mainly on the outpatient and specialty parts of the patient record, MyChart bedside is intended for use while a patient is admitted to the hospital. It provides online tools for tracking your progress toward discharge, and can be configured to provide patient education material.
What is Epic Rover?from quizlet.com
Epic Rover. Epic Rover is the module that uses mobile devices to allow Inpatient nursing staff to do review and documentation tasks.
What is Epic Haiku app?from quizlet.com
Epic Haiku is an App for Android and Apple that allows doctors to access a limited version of EpicCare Ambulatory. They can see and respond to test results, access their schedule, and see other clinical data on their patients
What is Epic Hyperspace?from quizlet.com
Epic Hyperspace is not a clinical module in itself, but rather the actual application client that is presented to users of most areas of Epic. When a nurse, doctor, therapist, or administrative staff launch Epic, the front-end software that is presented to them is called Hyper space.
How to change columns in Epic trackboard?
This can be done by clicking the wrench icon at the right-hand side of the ED trackboard screen. In the first tab, you can select which columns you want displayed on the full or side-by-side (SxS) trackboards for a given view. In the second tab, you can arrange the order or hide certain trackboard views from automatically displaying. Your organization may require certain columns to always be displayed (these will appear with a lock icon) and you are only able to add columns that your organization has decided to make available to you.
Why do physicians use order panels?
Some organizations may have created order panels available for all physicians to use to help expedite placing certain bundles of orders. If your organization has not created these, or you would like to create personalized versions for yourself.
Where is the CareEverywhere icon on the storyboard?
Click the CareEverywhere icon at the top of the storyboard on the left-hand side of the screen
How to view ED trackboard?
There are two ways to view the ED trackboard, traditional full-width or a newer, side-by-side view that allows access to significantly more information and functionality without having to leave the trackboard and open a patient’s chart. You can toggle between the two trackboard views using an arrow button that will either be in the middle of the screen while in the side-by-side view or at the right-edge of the screen while in full-width view.
Does Acep have a smart phrase?
ACEP has created some SmartPhrases that you may want to add to your SmartPhrase manager.
Can you link Epic to external health information exchanges?
While Epic can be configured to link to external health information exchanges, you can easily view patient information from other Epic organizations using CareEverywhere. For the most part, linking a patient’s records across Epic organizations is not an automated process, it requires querying specific organizations where the patient has been seen. Organizations must be individually queried to make matches, just because you see some organizations listed in CareEverywhere, doesn’t mean there aren’t others. If the demographic information closely matches between organizations, a match will be automatically suggested (meaning that you are not likely to find matches before patients are registered or patients who are undomiciled, do not have social security numbers, or have recently changed mailing addresses or phone numbers).
Can you do Epic on your own?
Things You Can Do on Your Own - Epic. People take the time to adjust settings on their smartphones, and the EHR should be no different. User settings can reduce the amount of time spent on clicks, typing, scrolling, and more. Emergency physicians should continue to update their user settings over time.
What is EMR billing?
The EMR is designed to optimize billing by making it easy to include many elements in documentation. However, this has fostered the idea that “more it better”, leading to the note bloat phenomenon in which notes frequently contain redundant, contradictory, superfluous, and/or out of date information.
How to make a problem list editable?
Right click on the imported problem list and “make editable” (Note: you can do this with any element in the note – use this functionality to remove things that may be irrelevant while keeping things you want)
Can you send a patient reminder to Epic?
If you feel you need to follow up on something in the future, you can make a patient reminder for yourself which can be delivered at future time. ( see tip sheet) Results can be sent to patients as Epic patient message or in a short letter (which you can route to your administrative assistant for mailing).
