Getting Started with Epic: Review a Patient's Chart

Summary

Provider tips on navigating the different sections of a chart, such as demographics, scanned documents and medications.

Body

Review a Patient's Chart

View Information From an Encounter

Demographics

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Within Epic Hyperspace, review patient demographic information from the Patient Storyboard or in the Demographics Activity. Demographic information is organized into logical sections featuring a recognizable icon and header.

1. Hover over the patient name on Storyboard to see additional information about the patient.

2. To access the Demographics Activity while in an encounter, navigate to the More Menu and select Demographics.

Rooming

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The History tab contains General, Social, and Pediatric information on a patient. If the patient is female there is an additional section of OB/GYN.

1. Click the Rooming tab, select History.

2. Click each section to view specific information.

3. Click the pencil icon on each header in the viewing pane to add or edit information for that section.

If the patient is 7 years or older, Birth Hx will be a read only section.

Chart Review

Encounters

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Keyboard shortcut Control+F launches a search box that appears at the top of the screen. If the text used in searching is found, all matches are highlighted.

 

Encounters tab houses all encounters created on a patient. Some may be hidden such as abstract or erroneous encounters.

1. Click on the Encs tab.

2. Unselect the Hide Add’l Visits filter to see all encounter types.

3. Click once on the row to select an encounter.

4. The visit information will appear in the viewing pane.

OnBase Scanned Documents

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The 'OnBase Scan Barcode' hyperlink opens a barcode sheet for the corresponding order in the Chart Review Links section for the Procedures, Labs, Referrals, Radiology, and Cardiology tabs. The barcode sheet is used to add a document and scanned into OnBase. The document type and date of service are required when the barcode is used to read and apply the order and patient information to the document. 

From Chart Review:

1. Click the Proc tab.

2. Click once on the result to open the details.

3. Scroll to the Links and click on OnBase Scan Barcode.

The OnBase barcode will display:

The "OnBase Scan Barcode" link is not visible in the following situations:

· If the order was not created in same Service Area as the current user's login department

· If the order is in a future or pending state

· If the order has been canceled

· If the Order type and class were not resulted through the scan interface (Order types of Procedures, Imaging, Lab, Referral, and ECG are available)

Report Viewer

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The Report Viewer is not available for all Encounter types.

 

1. From the Encs tab click on a row to open the select an encounter.

2. Report Viewer opens in a separate activity tab outside of Chart Review.

3. Orders placed in an encounter will appear on the right side of the report. Hover over the Orders Placed tile to view result details.

  • Normal results will be displayed with a checkmark on gray background.
  • Abnormal results exclamation points on a yellow background.

4. Click on the blue hyperlinks to display resulted orders in a separate report.

Meds

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1. Click on the Meds tab.

2. Both inpatient and outpatient medications will display.

3. Click on a row to see details about the medication in the viewing pane.

Labs

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1. Click on the Labs tab.

2. Click on a lab or procedure order.

3. Additional Card View of information appears on the right pane including Trending data.

Referral Tab

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In order to see the status or information of a Referral, click the Ref tab:

1. To see the details of a Referral click to select, information details will display on the side.

2. Print group Reviewed by [848052050] will display the user who last reviewed the referral’s results.

Bookmark Tab

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Bookmark relevant content in Chart Review so the provider can revisit it later. The Bookmark tab shows everything the provider bookmarked for the current patient in a tidy, ordered list. Providers can even see information bookmarked by other clinical staff.

For example, providers can ask support staff to bookmark relevant items before the provider sees a patient. The provider can also review what other providers on this patient's care team have bookmarked.

Adding a Bookmark

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1. Click on any tab in Chart Review and select an item.

2. Click the bookmark icon or Add to Bookmarks on the Chart Review toolbar. Optionally add a comment, which appears on the tab.

3. After bookmark is added or removed, the tab includes a red dot. The dot also appears when another user creates or updates their bookmark list for this patient.

Reviewing Bookmarks

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1. Go to the Bookmark tab to see the bookmarked items.

2. If another user has bookmarks for this patient, click in the Your Bookmarks field and select the providers name to see their bookmarks. Other user bookmarks cannot be edited.

3. Click to undo or redo any changes that were made to a bookmark, like removing the bookmark or editing a comment.

4. Remove the selected item from bookmarks by clicking the bookmark icon.

5. Click to add, remove, or edit comments for the selected item.

Details

Details

Article ID: 155956
Created
Fri 12/8/23 7:35 PM
Modified
Wed 6/5/24 1:35 PM

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