Surgeon work flow for surgical patient includes what navigators in Epic?

A navigator is

• a list of documentation tools
• sequenced to match a particular workflow
• most users use one to complete all or part of their workflows.

Move to the next

SmartList

 
• Mouse: Click the yellow forward arrow
• Keyboard: Press F2

A navigator is divided into sections

• each section has a line within the table of contents

• Initially, these sections are closed, as indicated by the arrow icon

• closed sections display summaries of information documented

• Pencil and paper icon mean the section can be edited

F9

Closes the currently open section.

F8

Moves to the next section

F7

Moves to the previous section

H&P notes include at least?

Information on a patient’s personal and family health history,including preexisting conditions

• A summary of physical exam findings, often broken down by body system
• The surgery plan
• A signature and date

Important part of Joint Commission accreditation includes:

• The timely filing
• easy access to an up-to-date H&P

The H&P is often used as the definitive source of information on a patient’s

medical condition.

Surgical consent form:

• H&P notes

• consent form must be on file before surgery begins.

On the day of surgery, the chart t must be verified and confirmed to have these two important documents

Physicians are the most common authors of H&P notes, though H&Ps may also be written or updated by other providers

 (CMS) and the Joint Commission consider the H&P current if:

• It is performed within 24 hours of an admission (but before a surgery starts)
• It was performed up to 30 days prior to an admission, and is updated before the procedure begins.
• a provider can indicate that the H&P was reviewed
• the patient was examined
• and document that there are no changes since the original H&P.

H&P notes that are dictated at the

time of admission but not yet transcribed and available in the medical record... 

NoteWriter

Other information pulls through automatically to the note as well such as the patient’s name, problem list, history, etc.

wildcard

• press

F2 on your keyboard

• Left Click to Pick-Right Click to Stick

   

choose the answers from the list provided to fill in your note

• Yellow SmartLists: single-select, allowing you to choose only one response
• Blue SmartLists: multi-select, allowing you to choose multiple options

Select a Choice from a Multi-Select (blue)

SmartList

• Mouse: Left-click
• Keyboard: Use arrow keys to move around and SPACEBAR to make a selection

Re-select

Choice from a SmartList

• Right-click the list and choose Reselect This SmartList’s Selections
• No keyboard equivalent

Save Choices in

a SmartLists

• Mouse: Right-click
• Keyboard: Press ENTER

First, if you catch the mistake right away, you can simply click the undo button

• Second, you can simply delete the text you don’t want and retype the

  correct information

• t

  hird, certain types of lists allow you to re-select their choices by rightclicking

Forgot to sign my note

• go back in to the H&P Notes section. Click

Edit to

• get back into the note
• Click Sign this time.

Orders

are the medications, procedures, tests, and other tasks that are carried out

by care givers.

Displays a read-only outline of the Order Set contents, useful for determining if it has the orders you are looking EU. You cannot actually select any orders from the preview

window.

Opens all selected Order Sets for documentation.

You must click this button before you can select and sign orders

from an Order Set.

1.    PrimaryProvider

2.    Location

3.    Procedure Date (and the requested surgery date)

4.    Patient Class

5.      Procedure

6.      Laterality

7.    Anesthesia

8.      Pre-op Diagnosis

Yes. Surgeons can manually override a preference card while placing an

order for the case request. To do so, they click the Change hyperlink next

to the

Card field in the order itself.

Phase of Care

The point in a patient’s care where an order should be administered.

Signed=authorized by a physician and immediately active in the system.

Signed and held=means that the order is authorized by a physician and

temporarily inactive in the system.

Keystrokes to move around a quickly in the navigator

F9= Close

F8= next section

F7= move back