Chart Review Flashcards

1
Q

How do you find information on a patient that does not have an appointment scheduled?

A

Epic toolbar- chart button

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2
Q

Which order first or last name do you search for patients?

A

Last,First

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3
Q

When in production what should you do when you search a patient and have several patients with the same first and last name?

A

Check all identifiers

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4
Q

What are the tabs that you see in chart review?

A

Encounters, notes, imaging, lab, meds, procedures, surgeries, consents, media, cardiology, letters, episodes, referrals, other orders, misc reports, LDAS

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5
Q

What is an encounter?

A

encounter in Epic is any contact between the patient and our organization.

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6
Q

What are some types of encounters?

A

outpatient appointment, a telephone call, or an
entire hospitalization

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7
Q

What do you need to do to see history and lab visits in the encounter tab?

A

Uncheck the Hide Add’l Visits box to see additional encounters

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8
Q

How do you sort information in each column?

A

clicking the column header, columns will sort alphabetically
or chronologically based on the type.

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9
Q

If you single click on a encounter what will happen?

A

A report pane will open up with information about that encounter

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10
Q

What extra hyperlinks are attached to an encounter?

A

Billing Info, History, or Orders placed during the encounter

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11
Q

Can you bookmark pertinent content in chart review to visit later?

A

Yes, click on the bookmark icon

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12
Q

If you click the bookmark icon what pop up shows up?

A

Comment

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13
Q

What type of notes will the notes filter show?

A

progress notes, nursing notes, notes for procedures or EKG impressions

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14
Q

What will the imaging tab show?

A

radiology results and impressions

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15
Q

What will the lab tab show?

A

Ordered, In Process, and Final Results labs.

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16
Q

What will the medication tab show?
What to uncheck to see historical meds?
Meds with a strikethrough indicate?
What 3 types of medication can be sorted by clicking the header?

A

past and current medications. Click the
checkbox to uncheck Current Meds Only to see a historical view of
medications. Meds with a strikethrough indicate that the order has been
discontinued. You may find it helpful to click the header to sort by
AMB/CAM/IP medication types.

17
Q

Some items that procedure will show?

A

biopsy or cath reports.

18
Q

What will the Surgical tab show?

A

Surgical Cases

19
Q

What will the Consents tab show?

A

E-signed or scanned into Epic

20
Q

What will the media tab show?

A

documents that are scanned into the medical record such as EKG
print outs or Power of Attorney documentation

21
Q

What will the cardiology tab show?

A

Will show the EKG-12 lead tracings. Impressions are viewable
in the notes tab.

22
Q

What will the letters tab show?

A

any letters sent to or on behalf of the patient

23
Q

What is an Episode?

A

episodes are a tool in Epic used to link content that shares the
same reason for visit.

24
Q

Examples of Episodes?

A

pregnancy, surgery, or workman’s compensation. Encounters are linked to the episode, which stores all pertinent information. This makes it easier to find information all in one place.

25
Q

How is one episode linked to another?

A

They are linked with each encounter

26
Q

What does the referral tab show?

A

view Service To orders and other referrals such as labs or
radiology.

27
Q

What do other orders tab show?

A

this is a catch all for non-medication or lab orders, such as
Durable Medical Equipment (DME).

28
Q

What does the Misc reports show?

A

allows you to locate and print documents such as
immunization reports or medication lists for your patient.

29
Q

Where would you find print out documents for immunization reports or medication list?

A

Misc reports tab

30
Q

What does the LDA tab show?

A

his section shows active and inactive lines, drains, and airways.

31
Q

How can you save a filter in chart review?

A

Click the Save as New Filter button and type
a name for your filter in the Caption field. Accept and point out the new filter check box below the Chart Review toolbar.

32
Q

What do you do if you don’t want to see that new filter you added?

A

I can uncheck my filter box or click the Clear Filters button. Click the filters button to close the filter selection box.

33
Q

What function let’s you send patietns info in chart review to another provider or pool?

A

Route function

34
Q

What do you click in the route function to send information to providers outside of AAH?

A

Click the Free Text button. Make sure to put fax number and a comment

35
Q

How do you change a routed message to a provider inbasket to sending a fax to the provider?

A

Click provider and click change address

36
Q

How do you close the chart in chart review?

A

Click the X

37
Q

How would you personalize your view to see only encounters that
apply to your clinical practice?

A

Use chart review filters to narrow down the encounters that you
see for a patient. Save filters to be used on any patient.

38
Q

Where can you find scanned copies of paper documents?

A

Scanned items go into the Media tab within a patient’s chart.