Getting Started with Epic: Pre-Charting Documentation

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• The Chief Complaint is not the diagnosis for the visit, but simply the reason for the visit. Users may need to add more than one chief complaint if the patient presents for multiple reasons.

1. Click on the Rooming activity tab.

2. In the Chief Complaint section, enter the reason for the visit, click Add.

3. One the Chief Complaint is selected, a comment box can be expanded for further documentation.

Customize the Chief Complaint section: Edit Speed Buttons

• From the Chief Complaint section of the Rooming Navigator:

1. Click the wrench icon.

2. In the Add a new reason field, search for a chief complaint, and click Add.

3. Each time the user clicks Add, the speed button is created for the chief complaint.

4. Click Alphabetize hyperlink to sort the speed buttons in alphabetical order.

5. Click Accept when all items have been added.

Customize the Chief Complaint section: Modify Layout

• From the Chief Complaint section of the Rooming Navigator.

1. Click the wrench icon on the far-right side of the Chief Complaint card.

2. Use the Add New report search field to browse and add other reports to display in the Chief Complaint card.

3. Drag and drop or use the arrows to rearrange the columns.

4. Click Accept to save changes.

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1. Click on the Vitals header.

2. Enter vital sign data in the appropriate fields.

• Specify a unit (lbs. or kg) when entering weight.

3. If applicable, record pain information, verify tobacco use, and document the date of a female patient’s last menstrual period.

4. If a user needs to document an additional set of vitals later in the visit, they can click the New tab. For example, a user may record a second set of vitals if the patient’s blood pressure was unusually high upon arrival.

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Please refer to the Getting Started with Epic: Update a Patient's Allergies article for an overview on adding new/editing existing allergies.

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• To help maintain an accurate list of medications the patient is taking, use the Med Documentation activity.
• Users may also document any patient reported medications in this activity.

Verify the Patient's Pharmacy

1. Ask the patient if the pharmacy listed in the Medication Documentation section is accurate.

2. To change or add a pharmacy, click Select the patient’s pharmacy or click on the existing pharmacy listed.

3. Choose the appropriate pharmacy and click Accept.

• The pharmacies that appear on the Suggested tab are those that the patient prefers or has used previously.
• Users can add the most used pharmacies to the Suggested tab for all patients by clicking the wrench icon at the top right of the Pharmacy Search window.
• If necessary, users can search for another pharmacy on the left side of the window.
• To assist in retrieving accurate results, enter the Patient and clinic’s nearby zip codes.
• After one pharmacy is added, users can save another pharmacy for the patient by clicking Add.
  • This is useful when a patient prefers some prescriptions to be filled at a mail order pharmacy.