After selecting the patient on the PAU Status Board, you will be presented with the following:
We will now focus on the “Evaluation” contained on the right-hand side of the screen. “
Right to Write
From your hands-on session, remember that there are multiple tabs at the top of this section. Clicking the arrow
will take you to the information in a “read only” format. Clicking the tab will take you to the section with the ability to enter information.
The meat and potatoes of the Evaluation section is the “Pre-Evaluaton”/Problem List. Let’s focus on this. Click on “
“My Note” opens up ready to accept any problems we deem to be relevant from the problem list. Notice the text highlighted in blue. This is LINKED information that has been populated in other parts of the system and imported into the note.
” in EPIC functions similar to SIMS Preop Manager. We have attempted to copy the format that we have been using for many years. At the top, you see the body systems. We have separated Cardiovascular into CV, CV-Valves, CV-Vent Fx and CV-Rhythm in order to reduce the number of choices under a specific system.
Within each system, there will be diagnoses related to that system.
Every descriptor has a
’ve means you have the problem,
means you don’t have the problem (relevant negative).
Clicking on a descriptor adds the problem to the Problem List. This is a central repository available to all physicians and nurse practitioners, hence you will see all the patient’s problems, not just those added by you.
As an example, “
The following “New Problem” box appears.
At this point, there are many options.
In the overview area, I typed, “Severe: AVA 0.6 cm
and hit “
You will see below, why, in most circumstances, you probably will NOT enter information into this Overview.
What has happened?
Aortic Stenosis has been added to the Problem List
As it is a condition that we included in our “
” tab, it is automatically considered
As the problem is
, it has migrated over to the anesthesia note
My comment did NOT go to the note. It remains with the problem for any physician to read.
Why didn’t my comment, “Severe: AVA 0.6 cm” to migrate to the note?
How do I get the comment, “Severe: AVA 0.6 cm” to migrate to the note?
Click on the small
icon located in the two spots noted in the diagram.
A dialogue box appears and you type your comment, then click the green check box.
If you had chosen this option originally, the comment would only be visible in the note and not in the problem list. As anesthesiologists, we would prefer the former. By typing it into the overview, you are being a good corporate EPIC citizen so that the comment is there for all to see.
We have intentionally kept the descriptors at a very low level. Using Mitral insufficiency as an example, an anesthesiologist wants to know the degree of insufficiency. Above, we used the
function to accomplish this.
Another way to do this is as follows.
Click on “DxReference”
You are presented with more
concepts related to mitral insufficiency. All share the same ICD code. The patient has “Severe mitral insufficiency”
Click on the icon adjacent to the more precise diagnosis.
Several things have now happened. The diagnosis in the problem list has
from “Mitral insufficiency” to “
Severe mitral insufficiency
”. This also appears in our note.
The final thing from the Problem List is to add a diagnosis to the patient’s history. To do this, click on “
Add to Hx
”. In this example, we will use, +Hypertension-
Hypertension is now added to:
The problem list
Patient’s medical hx (click “Add to Hx”)
Anesthesia Note (click “Accept”)
This patient also has “Knee pain, chronic” on the Problem List. Why is it not in our note?
It is pretty clear that knee pain is NOT an issue we would typically worry about in a review of systems. It certainly does not live under our “Msk/Breast” tab. Because it does not live there, it is not considered
. If it is not considered relevant, it won’t automatically populate the anesthesia note.
However, if I decide to make it relevant by ticking the box, it will immediately show up in the note.
Over time, there may be many problems occupying this list, some of which may be important to us. Keep in mind that simply making the problem relevant will move it over to the anesthesia note. As these problems are not found in our list, the problem will live in an “Other” category.
The problem list can be filtered by lists (hit the wrench to make this available), Changing any of these is not an issue. It is unique to you. You are not affecting what others see.
The problem list can also be filtered by relevance, hospital, sort priority. Changing any of these is not an issue. It is unique to you. You are not affecting what others see.
Working within the Note
Remember that you are not restricted from entering or deleting text within the note. Hover over the tools below to learn what they can do for you.
Over time, you may find yourself entering the same text as determined by your writing style.
Creating a smart phrase (.phrase) can reduce this task to a couple of key strokes.
If you have a situation where information is not moving to the note, click on this icon to refresh your note.
Copy Previous note
This is similar to the “Copy Forward” function in SIMS. You may choose to use this to generate a Pre-Eval note on the day of surgery as the anesthesiologist of record and add/modify/delete based on discussions you had with the patient.
I am in the body of the note. The blue highlighted text is looking for information that can be linked in from other areas of the chart. In this example, there is nothing. The note can be cleaned up by simply highlighting what you don’t want to see and hitting “delete” on the keyboard.
Place your cursor outside any highlighted area (blue or yellow) and you can free text.
Complete the Physical Exam
Don’t forget about the “Healthy Patient” macro.
Complete the Anesthesia Plan
and “Sign” the note.