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A work in progress – and likely to change as we learn how EPIC works. Here are some suggestions for getting started in PAU EPIC Anesthesia Documentation and Workflow (as of May 28)

Epic Support Mellissa Waggott 613-979-1420

We’ve captured a video of Sarika working through her 1 st EPIC patient documentation in the PAU today. Hopefully this will help others that are getting started when they are first booked in the PAU. Please feel free to edit this document – it’s a work in progress.

https://www.youtube.com/watch?v=0YP3BaGH5Tw

  1. Open Hyperspace PRD
  2. Open your patient; once opened look at the top on the left-hand side of the screen in the PAU section  This is the REVIEW AREA.
  3. Click on Allergies – check “mark as reviewed”
  4. Then click on medications – check “mark as reviewed”
  5. Go to History
    1. Enter any relevant information for scoring systems (go to Scoring or to the bottom of the History section to find DASI, STOPBANG, Frailty and RCRI scoring). Check “mark as reviewed”

 

  1. GO to the Evaluation Area on the right side and click on “Pre Evaluation” or scroll down to +Create Note in the Preprocedure Evaluation. This will open the anesthesia note.
  2. Go to Problem List to start populating the patients’ problems. (R hand side of screen)

a.       Choose a system problem (e.g. Hypertension), accept (click on the relevant + or -), this will open a window identifying the problem (Hypertension) and displaying the problem in the Note as “Hypertension”. The display can be edited. Additional information can be added by clicking the notepad icon next to the problem. If you cannot find a problem, search for it in the open text box. Additional information can be added by clicking on the small notepad icon to the right of the medical problem. **If you wish, click the button at the bottom left (Add to Hx).  This will move this diagnosis over to the medical history in the review section. Hit accept to move the diagnoses to your note. 

8.       At the top of the note, click on “ Physical Exam” and enter information.

  1. At the top of the note, click on “Anesthesia Plan” and enter information.  You can summarize your assessment in the Summary box at the bottom of this section.
  2. Now you will want to clean up the note.  Go to the top of the Anesthesia Note and edit the first opening sentence. It will identify the patient by name, age and sex and states this patient is seen in consultation for the following: - edit this to enter the surgical procedure and the date of surgery. Hopefully this will eventually automatically populate with this information.
  3. Review the Preoperative Anesthesia Note. There may be some information that you feel is irrelevant. You can select and delete any information in the note as you wish.
  4. Finally, if you wish, you can provide a summary of the patient and your recommendations at the bottom of the chart.  Also, you can free text anywhere in the note (click outside of any blue or yellow)
  5. Once you are happy with the contents of the note, “Sign” at the bottom

 

  1. Go to Order set and open it. You need to choose “Anesthesiologist Preoperative Orders”. Right click and favourite this order set as it is our standard PAU order set.
  2. You must click on the red exclamation mark to identify the patient is fit for surgery.
  3. Sign the orders.
  4. If you are ordering tests/consults/outside records other than suggested by the medical directive, add a “Task” (if your task is not in the drop-down list, use “Clearance-Other”) and leave a comment if necessary (ex. Records from Renfrew).  This will allow the charge nurse to ensure we follow up.
  5. Before the patient leaves, ensure that you have reviewed the nurses printed “Pre-procedure instructions” indicating what to do with their meds.  (this text is also viewable in the chart after Pre Admission Summary).
    1. If there is nothing to change you will still need to co-sign the instructions in EPIC. To do so:  To do so click on “Notes” (leftmost column), select the correct note, – co-sign. 
    2. If you need to make changes there are 2 options.
      1. Make changes by hand on the patient copy and send them off.  In EPIC, click on “Notes” (leftmost column), select the correct note, Edit – co-sign. 
      2. Or, make the changes in EPIC and print for the patient. Click on “Notes” (leftmost column), select the correct note, Edit – co-sign.  Unfortunately, you cannot print from this workspace.  Click “Chart Review, select notes.  *Unclick “default filter” otherwise you will not see the correct note.  Print. Then give it to the patient. (You may wish to complete this step before seeing the patient, especially if you will chart after leaving the patient)

Remember that you can free text anything you wish.

Hope this helps

Pat Sullivan/Sylvain Gagné/Ian Zunder

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