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n2b8me

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User Dictionary --> Auto Correct.
I use these all day everyday and it make my chart expand into something legible with minimal effort.
80 yo f bib ems sp syn. pt co cp 1 d pta. ho copd, chf, dm. found by snf staff on floor in br co cp. + diap, no nvd no sob no aloc.
yest noted by snf to have brbpr.
BECOMES
80 years old female brought in by emergency medical services status post syncope. Patient complaining of chest pain 1 days Prior to arrival . History of Copd , congestive heart failure , diabetes . found by skilled nursing facility staff on floor in bathroom Complaining of Chest pain . + diaphoresis , no nausea, vomiting, or diarrhea. no shortness of breath no altered level of consciousness.
Yesterday noted by skilled nursing facility to have bright red blood per rectum .

Also using a dotphrase with a lot of *** spacers in it and you can F2 through the whole chart quickly.
 

gutonc

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User Dictionary --> Auto Correct.
I use these all day everyday and it make my chart expand into something legible with minimal effort.
80 yo f bib ems sp syn. pt co cp 1 d pta. ho copd, chf, dm. found by snf staff on floor in br co cp. + diap, no nvd no sob no aloc.
yest noted by snf to have brbpr.
BECOMES
80 years old female brought in by emergency medical services status post syncope. Patient complaining of chest pain 1 days Prior to arrival . History of Copd , congestive heart failure , diabetes . found by skilled nursing facility staff on floor in bathroom Complaining of Chest pain . + diaphoresis , no nausea, vomiting, or diarrhea. no shortness of breath no altered level of consciousness.
Yesterday noted by skilled nursing facility to have bright red blood per rectum .

Also using a dotphrase with a lot of *** spacers in it and you can F2 through the whole chart quickly.
I'm not in EM but this is how my notes are done. I've got enough templates and dot phrases that for 80+% of my charts, I will typically only type out 5-10% of the actual words in it. Faster than dictating.
 

diphenyl

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I hated the built in epic chart format. The previous EMR we has used was IBEX which I thought the format on that was much more EM friendly. So I created a macro which basicly populated a blank note with the format of chart that I had created in word. I even used [__] in the chart which i then could put my icon in and put an x to make it like a check box. An example would be:
Disposition:
[__] admit
[_x_] discharge

I also built macros I could through in for all the normal radiology studies we would routinely get in the ED and put in the findings I normally look for. This way I could just highlight and change them as necessary. I built hard stops into these macros so that I would never forget to put in the number of views etc for billing purposes. I also did this in my consultant macro so I would remember to put the name of the admitting MD I talked to. I also built some nice smart phrases for MDM's the most common dispos. I had one for pediatric head injury, admit cp r/o ACS, asthma/ copd exasp. Building these up as you do them is so hopeful. It takes about a good month to do when you get it. I just make sure to save it as I see each type of patient/ document different things.

One of my buddies figured out a way to take pictures with his iphone and get it into the EMR. He does it with things like lacs and abscesses. He has also started doing it with decubiti because of the high liability associated with them. The RN's do take pics some of the time when the patient is going to be admitted but he does them any time he finds them for cya purposes.
 

southerndoc

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User Dictionary --> Auto Correct.
I use these all day everyday and it make my chart expand into something legible with minimal effort.
80 yo f bib ems sp syn. pt co cp 1 d pta. ho copd, chf, dm. found by snf staff on floor in br co cp. + diap, no nvd no sob no aloc.
yest noted by snf to have brbpr.
BECOMES
80 years old female brought in by emergency medical services status post syncope. Patient complaining of chest pain 1 days Prior to arrival . History of Copd , congestive heart failure , diabetes . found by skilled nursing facility staff on floor in bathroom Complaining of Chest pain . + diaphoresis , no nausea, vomiting, or diarrhea. no shortness of breath no altered level of consciousness.
Yesterday noted by skilled nursing facility to have bright red blood per rectum .

Also using a dotphrase with a lot of *** spacers in it and you can F2 through the whole chart quickly.
What menu is user dictionary under? The only option I have is spell check.
 

Raryn

Infernal Internist / Enigmatic Endocrinologist
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What menu is user dictionary under? The only option I have is spell check.
For me it's tools->spell checker->user dictionary. Probably varies depending on your version/implementation of EPIC.

I don't use the user dictionary though, I made .phrases for everything, including a basic plan for the most common conditions I encounter.
 

gro2001

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I hated the built in epic chart format. The previous EMR we has used was IBEX which I thought the format on that was much more EM friendly. So I created a macro which basicly populated a blank note with the format of chart that I had created in word. I even used [__] in the chart which i then could put my icon in and put an x to make it like a check box. An example would be:
Disposition:
[__] admit
[_x_] discharge

I also built macros I could through in for all the normal radiology studies we would routinely get in the ED and put in the findings I normally look for. This way I could just highlight and change them as necessary. I built hard stops into these macros so that I would never forget to put in the number of views etc for billing purposes. I also did this in my consultant macro so I would remember to put the name of the admitting MD I talked to. I also built some nice smart phrases for MDM's the most common dispos. I had one for pediatric head injury, admit cp r/o ACS, asthma/ copd exasp. Building these up as you do them is so hopeful. It takes about a good month to do when you get it. I just make sure to save it as I see each type of patient/ document different things.

One of my buddies figured out a way to take pictures with his iphone and get it into the EMR. He does it with things like lacs and abscesses. He has also started doing it with decubiti because of the high liability associated with them. The RN's do take pics some of the time when the patient is going to be admitted but he does them any time he finds them for cya purposes.
Forgive my ignorance, but what is the high liability issue with decubiti for emergency physicians? Do you mean like missing that one could be a source of infection? Would you then take a picture to 'prove' that it didn't look infected?
 

Raryn

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Forgive my ignorance, but what is the high liability issue with decubiti for emergency physicians? Do you mean like missing that one could be a source of infection? Would you then take a picture to 'prove' that it didn't look infected?
Liability is for the hospital. If you don't appropriately document that they're present on admission (which is a nursing job everywhere I've been because most physicians never bother rolling the patient over) and they're noted sometime after admission, the insurance companies will assume that the patient developed them inpatient due to inadequate care (i.e. wasn't turned enough). Then any care for those decubiti will not be paid for.
 
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gro2001

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Liability is for the hospital. If you don't appropriately document that they're present on admission (which is a nursing job everywhere I've been because most physicians never bother rolling the patient over) and they're noted sometime after admission, the insurance companies will assume that the patient developed them inpatient due to inadequate care (i.e. wasn't turned enough). Then any care for those decubiti will not be paid for.
Right, that was the one issue I could think of.
 

BAM!

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Liability is for the hospital. If you don't appropriately document that they're present on admission (which is a nursing job everywhere I've been because most physicians never bother rolling the patient over) and they're noted sometime after admission, the insurance companies will assume that the patient developed them inpatient due to inadequate care (i.e. wasn't turned enough). Then any care for those decubiti will not be paid for.
seems like a lot of work for not much return.
 

BAM!

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Anyone know of a resource/list of commands you can type into the smart phrases? For example, @Age@
 

doctalaughs

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Anyone know of a resource/list of commands you can type into the smart phrases? For example, @Age@
What do you mean? Basically any smartphrase or smartlink (even one you made) can be put inside @...@ and nest within another defined smartphrase. Epic has an excel spreadsheet of all system smartlinks you can find it on their website.


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gutonc

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What do you mean? Basically any smartphrase or smartlink (even one you made) can be put inside @...@ and nest within another defined smartphrase. Epic has an excel spreadsheet of all system smartlinks you can find it on their website.
I think he just means a list of smartlinks/smartphrases.

The downside to the Epic list is that, it's just the baseline list and doesn't include ones added at the system level (or remove ones that are replaced at the individual system level). There is reportedly a magical list at my home institution, but nobody, including my Epic ITG insider and Physician Epic director, have any idea where it is.

I use Epic at 3 different hospital systems on a weekly basis. They are so different from each other that, other than the icon on the desktop being the same, they might as well be different EMRs. Even simple things like: .lastcbc or .lastcmp appear differently in all 3 systems.

That said, it's the devil I know. And I dread having to round at the one (of 9) hospitals I have privileges at that uses Cerner.
 
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styphon

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Liability is for the hospital. If you don't appropriately document that they're present on admission (which is a nursing job everywhere I've been because most physicians never bother rolling the patient over) and they're noted sometime after admission, the insurance companies will assume that the patient developed them inpatient due to inadequate care (i.e. wasn't turned enough). Then any care for those decubiti will not be paid for.
This comes from medicare policy (which private insurances copy) which classifies certain things as "never events." If any of these occur during hospital stay, the insurance will refuse to pay. The most common being decubitus ulcers, foley associated UTI, and surgical site infections.
 

doctalaughs

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I think he just means a list of smartlinks/smartphrases.

The downside to the Epic list is that, it's just the baseline list and doesn't include ones added at the system level (or remove ones that are replaced at the individual system level). There is reportedly a magical list at my home institution, but nobody, including my Epic ITG insider and Physician Epic director, have any idea where it is.

I use Epic at 3 different hospital systems on a weekly basis. They are so different from each other that, other than the icon on the desktop being the same, they might as well be different EMRs. Even simple things like: .lastcbc or .lastcmp appear differently in all 3 systems.

That said, it's the devil I know. And I dread having to round at the one (of 9) hospitals I have privileges at that uses Cerner.
True, the epic list are just the standard ones. But the IT people lock down the tool so users cant simply go into the smartlink section (kind of like the smartphrase section) to look around to see what is available and what has been disabled/renamed etc. Its actually quite easy to program new links to do almost anything you want, if you know how and its allowed.

Some of my favorites (if your system has not disabled or renamed them):

Dot lastlabx which allows you to input parameters on all the exact labs you want pulled for the last X times

Dot risrslt pulls narrative impression for imaging

These are more customizable since they have input parameters


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gutonc

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True, the epic list are just the standard ones. But the IT people lock down the tool so users cant simply go into the smartlink section (kind of like the smartphrase section) to look around to see what is available and what has been disabled/renamed etc. Its actually quite easy to program new links to do almost anything you want, if you know how and its allowed.

Some of my favorites (if your system has not disabled or renamed them):
Well this is the key, isn't it? If it's allowed and if it hasn't been disabled or renamed. Which you'll never know if you're not allowed to go looking around.
 

doctalaughs

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Well this is the key, isn't it? If it's allowed and if it hasn't been disabled or renamed. Which you'll never know if you're not allowed to go looking around.
Very true. Often they will have a non production test server which you may convince them to allow you access to poke around. Thats the only way I was able to see everything and make some useful stuff for myself.


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D

da8s0859q

Not really a trick, but a question for the masses: in ED notes, I've spent my entire residency dictating free text for HPI and using homegrown Dragon exams and the like. I never found it too useful to use the HPI tab to fill in an HPI for any given complaint.

But what about the MDM tab? Any utility in using this so as to not miss some detail which keeps complexity at a level sufficient to not get downcoded? I typically just dictate that labs and/or imaging was reviewed, considered this and this and this, why not, blurb about course, consults, so forth, but some of the information in the MDM tab I wouldn't think to mention there -- that I got some history from mom, that I reviewed the chart even when I did, so forth.

Just trying to optimize billing going into my attending position next month. Not sure if I ought to just be using those checkboxes.
 
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BAM!

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can someone post a link to the EPIC list? I can't seem to find it on their website.
 
D

da8s0859q

Bumping my own thread... I have a whole lot of Epic-isms tailored to my own OCDness, but I'm trying to find ways to keep notes "good" while being better / seeing more / being more efficient than I am.

The HPI forms (HPI macros) in Epic -- does anyone enjoy these? Seem very, very granular to me -- for better or worse. Certainly a coder/biller's friend. Debating doing this in-room with patients to speed up what is otherwise dictating when I leave the room, or at least doing it outside the room if need be. Feel like it'd be potentially faster to click through elements, and would be more to-the-point in the chart, but... dunno.
 

TrumpetDoc

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For those with EPIC and scribes.
Can you and your scribe be in a chart contemporaneously so you can put in orders as they are charting?
 

Raryn

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For those with EPIC and scribes.
Can you and your scribe be in a chart contemporaneously so you can put in orders as they are charting?
Never worked with a scribe, but all the flavors of EPIC i've seen don't lock out orders if someone else is doing something unrelated in the chart.
 

gutonc

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For those with EPIC and scribes.
Can you and your scribe be in a chart contemporaneously so you can put in orders as they are charting?
On the outpatient side, orders are the only thing that are locked out when multiple people are in the chart.

I don't know how it works on the hospital side, but I suspect that is less true in that setting.
 

southerndoc

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Reviving an old thread...

Does anyone know how to automatically bring in a macroblock? I have several notes (default, trauma, stroke, etc.) that will bring up templates. I have several "default" exams that I change a few things on each time, but the basis is the same.

So if the smartblock is "phyexambyage" (physical exam by age), and my normal macroblock is named default, how would one bring this up in a note so that the default exam is autochecked? @[email protected] brings up the smartblock, but for the life of me I cannot figure out how to bring up the macroblock by default.
 

gutonc

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Reviving an old thread...

Does anyone know how to automatically bring in a macroblock? I have several notes (default, trauma, stroke, etc.) that will bring up templates. I have several "default" exams that I change a few things on each time, but the basis is the same.

So if the smartblock is "phyexambyage" (physical exam by age), and my normal macroblock is named default, how would one bring this up in a note so that the default exam is autochecked? @[email protected] brings up the smartblock, but for the life of me I cannot figure out how to bring up the macroblock by default.
I think I understand what you're trying to ask. But let's just make sure.

In your default note template (what you're calling a macroblock, although I've never heard or used that terminology before...but whatever), you have a default PE smartblock called @[email protected] and you want to have it be autofilled (more or less) when you include it. Is that the question?

If it is, here's the answer...I think.

At the top of your note containing SmartBlocks, there should be buttons for every smartblock.
upload_2018-4-4_12-16-7.png

Click on that button (ROS in this case) and you'll get the NoteWriter option:
upload_2018-4-4_12-17-4.png

Now fill in your default exam/ROS/whatever and then click the pen and choose "Create Macro from current data". Then name it, and you'll see it pop up there like mine (negative, anxiety, fatigue). Then when you want to use that macro, click the button, and away you go. It's not quite what you want, but it's only 2 clicks. You'll also have all of the Smartblock macros available regardless of which template you're using at the time.

Did I answer the question you were asking?
 
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southerndoc

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@gutonc That's what I'm doing now.

I have several templates already where instead of clicking "my note" in the intro screen, I have different notes set up: default, trauma (major), trauma (minor), STEMI, code FAST, STEMI alert, medical alert, etc.

I want to expand this so that when I click the STEMI note button from the notes tab under "ED Provider Notes," it will automatically bring up the physical exam already populated with that macroblock (that's what Epic calls them). So I don't have to click the physical exam tab and then click whatever macroblock I wanted. For instance, I would create a tab on the main screen that said "Asthma." Clicking it would bring up a ROS with already clicked tabs and physical exam with already clicked tabs.
 

gutonc

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@gutonc That's what I'm doing now.

I have several templates already where instead of clicking "my note" in the intro screen, I have different notes set up: default, trauma (major), trauma (minor), STEMI, code FAST, STEMI alert, medical alert, etc.

I want to expand this so that when I click the STEMI note button from the notes tab under "ED Provider Notes," it will automatically bring up the physical exam already populated with that macroblock (that's what Epic calls them). So I don't have to click the physical exam tab and then click whatever macroblock I wanted. For instance, I would create a tab on the main screen that said "Asthma." Clicking it would bring up a ROS with already clicked tabs and physical exam with already clicked tabs.
Well...then I'm of no use to you.
 

EM4life

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Not sure if it's an EPIC hack, but to make my charts more reader friendly, I generally bold the MDM and put it at the very top of my note. That way, it's my words, and it's a flowing dictation that makes sense to the reader. Between all the random crap that's populated into the note and clicky box histories and physicals, I want to see what the doctor really was thinking and so I put it in bold at the top of my note as opposed to the end. I also put all my updates subsequent to that at the top as well.
 

LaBusqueda

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I really like just doing the note via the free text blank note and having a note already done with all the needed .dot phrases already in there.
Have * wildcards for nessesary coding stuff (opqst etc).


Example. (Names of .dot phrases are just jock examples-kind of product-specific if I remember.

HPI= .phrase for CC, age, ID stuff. I (scribe) dragon in the prose. *’s for opqst for coders.

ROS = .personal ROS phrase having most coveted in HPI prose

Past hxs = .phrase to populate automatically same with allergies, meds.

PE = .edVS and .personal PE template (mine is default to level 5 just via visual and basic exam of heat lungs)

MDM.
(.dot phrases are for example only. Each hospital has its own names for these things)
.ed meds
.rad results
.ed labs
.edekg
Etc

MDM prose or pre done .phrases for MDM (.whatever rule you want, .critcaretime, .chest painDC, etc)


Impression = .ed Dx
Dispo Xion's mATX case*

The entire thing load with a simple .mychart and bam chart mostly done




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LaBusqueda

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Been a few years since I changed jobs and currently not on EPIC. However the hospital let us know EPIC will happen soon.

I was curious, has EPIC added .phrases that are globally available for the various ED clinical rules like HEART etc. ones that would auto pop relevant pasht Hx/documented RFs etc and have *’s for the subjective stuff?
As of a few years ago we had to make our own, at least our hospital didn’t have them/purchase them.


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shoal007

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There are so many different flavors of epic. Some have the scores built in, on a special tab in notewriter no less. Others do not.

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LaBusqueda

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There are so many different flavors of epic. Some have the scores built in, on a special tab in notewriter no less. Others do not.

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That is a really infuriating aspect of their ploy.
Those should be globally available.


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bikERdoc

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Has anyone ever taken a course on this stuff? I know there are some consulting firms out there and whatnot that will come to your hospital. Wasn't sure if there was anything out there for docs who are interested in EMR optimization. Seminar, acep conference, etc.?
 

southerndoc

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Not that I've seen, but I've thought of doing some. I have a lot of things optimized. I have one-click order sets for flank pain (automatically orders labs, CT, ketorolac, morphine, ondansetron PRN -- even has left/right on CT for indication), appy, gallbladder, pregnancy (first and second/third trimester, with/without fluids), chest pain (general, STEMI, high risk with heparin, PE with d-dimer, PE with CTA, dissection, etc.). Seriously, a lot of my order sets are just a few clicks (one to open, one to sign) and done. It's actually more time consuming when our screener out front puts in screening orders. Then I have to go through and see what they did/did not order.

I have macros for review of systems (default, chest pain, viral illness, headache, etc.) and a ton of physical exam macros (default, chest pain, back pain, trauma negative, trauma head injury, trauma neck pain, asthma/copd/chf (mild and distressed), dehydration with and without tachycardia, appy, diverticulitis, etc.). Documenting is pretty easy. A few clicks to bring up the macro and then change whatever needs to be changed (murmur, guarding, etc.).

That coupled with dictation means I can knock out a chart in <1 minute. Another minute to do the MDM/summary in the end. I'm tinkering with templates now to document the HPI more quickly.

I have a GoToMeeting account and can arrange a web presentation if people are interested. I can host up to 100 people (I have to use it for EMS training).
 

LaBusqueda

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Not that I've seen, but I've thought of doing some. I have a lot of things optimized. I have one-click order sets for flank pain (automatically orders labs, CT, ketorolac, morphine, ondansetron PRN -- even has left/right on CT for indication), appy, gallbladder, pregnancy (first and second/third trimester, with/without fluids), chest pain (general, STEMI, high risk with heparin, PE with d-dimer, PE with CTA, dissection, etc.). Seriously, a lot of my order sets are just a few clicks (one to open, one to sign) and done. It's actually more time consuming when our screener out front puts in screening orders. Then I have to go through and see what they did/did not order.

I have macros for review of systems (default, chest pain, viral illness, headache, etc.) and a ton of physical exam macros (default, chest pain, back pain, trauma negative, trauma head injury, trauma neck pain, asthma/copd/chf (mild and distressed), dehydration with and without tachycardia, appy, diverticulitis, etc.). Documenting is pretty easy. A few clicks to bring up the macro and then change whatever needs to be changed (murmur, guarding, etc.).

That coupled with dictation means I can knock out a chart in <1 minute. Another minute to do the MDM/summary in the end. I'm tinkering with templates now to document the HPI more quickly.

I have a GoToMeeting account and can arrange a web presentation if people are interested. I can host up to 100 people (I have to use it for EMS training).
I forgot how much I missed being able to Uber customize orders!
Can’t wait for that.
Have you dabbled in dragon advanced scripting to order via dragon?
I had to do this as we could not edit or make “sets” just our own individual orders.
When we get our roll out I will insist we have ability to creat our own sets.

Looks like you like note writer with macros. I tried to like that so many times but always went back to blank with a pre done .dot phrased to the max chart.
Either way, when you optimize a chart any way “you” like it one can really be done in 1-2 min, no joke!




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LaBusqueda

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I went into my last job that had already used Epic.
Soon we will be rolling it out.
It’s not very close yet, more than a year.

I have asked to be involved EARLY to give input on stuff we want. We have a great relationship with the hospital and ED throughput is way important so I hope they let us have what we feel will help the most.

Anyone else been through a roll out process?
How much input did you have in the ED/hyperspace layout/options/process’s??


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shoal007

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We rolled out in the past couple years and really didn't have much say. #1 factor was billing. IE use the crap ROS and PE click boxy stuff so that it easier on the billers... Don't get me started as it takes 5 seconds plus to go into each subsystem for physical exam.

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southerndoc

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I have not used Dragon for orders. I'm a little leary to do that with my mumbling at the end of a shift. :O

I may ditch the physical exam template and just use everything free text with ability to use in dragon. Perhaps an "insert asthma template" with defaults for everything would work.
 

Lex81

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Can anyone tell me how to access old vitals on a patient? Specifically in a comparative table as labs would typically be presented. I've worked a version of Epic in the past where this was possible, though now at a new facility and I can't figure out how to bring that up again.
 

littlejuan

10+ Year Member
Jul 4, 2007
304
116
Status
Attending Physician
Not that I've seen, but I've thought of doing some. I have a lot of things optimized. I have one-click order sets for flank pain (automatically orders labs, CT, ketorolac, morphine, ondansetron PRN -- even has left/right on CT for indication), appy, gallbladder, pregnancy (first and second/third trimester, with/without fluids), chest pain (general, STEMI, high risk with heparin, PE with d-dimer, PE with CTA, dissection, etc.). Seriously, a lot of my order sets are just a few clicks (one to open, one to sign) and done. It's actually more time consuming when our screener out front puts in screening orders. Then I have to go through and see what they did/did not order.

I have macros for review of systems (default, chest pain, viral illness, headache, etc.) and a ton of physical exam macros (default, chest pain, back pain, trauma negative, trauma head injury, trauma neck pain, asthma/copd/chf (mild and distressed), dehydration with and without tachycardia, appy, diverticulitis, etc.). Documenting is pretty easy. A few clicks to bring up the macro and then change whatever needs to be changed (murmur, guarding, etc.).

That coupled with dictation means I can knock out a chart in <1 minute. Another minute to do the MDM/summary in the end. I'm tinkering with templates now to document the HPI more quickly.

I have a GoToMeeting account and can arrange a web presentation if people are interested. I can host up to 100 people (I have to use it for EMS training).
How do you make custom order sets?
 
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