Lessons 1 & 2 Flashcards
What are date shortcuts for 2 days ago and 1 week from now? (Select one.) A) d-2, w-1 B) d-2, w+1 C) t-2, w-1 D) t-2, w+1
D) t-2, w+1
True or False: To most efficiently completion match, enter the first few letters of the word you want to look up and then click the magnifying glass.
False (press Enter)
In the exam room, the nurse opens Lisa’s encounter. When she is done, Dr. Smith will use this room for her visit with Lisa. Therefore, when done rooming, the nurse should: (Select one.)
A) Exit Lisa’s workspace and secure the workstation.
B) Keep Lisa’s workspace open and secure the workstation.
C) Keep Lisa’s workspace open and log out.
D) None of the above
B) Keep Lisa’s workspace open and secure the workstation.
True or False: You are limited to choosing one reason for visit per encounter.
False
A nurse looks up a reason for visit by typing “Twisted ankle.” She selects it and “Ankle sprain” populates the field. This is because: (Select one.)
A) “Twisted ankle” is a synonym for “Ankle sprain.”
B) “Ankle sprain” is a synonym for “Twisted ankle.”
C) Neither one is a synonym.
D) Both are synonyms.
A) “Twisted ankle” is a synonym for “Ankle sprain.”
True or False: You should mark a medication as Not Taking if the patient is allergic to it.
False
In a patient header, which of the following means that allergy-related documentation exists in the patient’s chart? (Choose all that apply.) A) Sulfa drugs… B) Unknown C) No known allergies D) None of the above
A) Sulfa drugs…
C) No known allergies
True or False: To move from field to field in the Vital Signs section, press Tab.
True
True or False: When documenting a patient-reported medication, a provider name is not required.
True
For a result message to be sent, what status must you select for a result in the Enter/Edit Results activity? (Select one.) A) Abnormal B) Normal C) In Process D) Final
D) Final
Where should you document how the patient can take care of herself such that the information appears on the AVS? (Select one.) A) Preview AVS B) Follow-Up C) Patient Instructions D) Sign Visit
C) Patient Instructions
True or False: To enter an LOS code for the visit, you must use an LOS button.
False
What detail about a medication does Epic use to decide if the medication is a current medication? (Select one.) A) Its ending date. B) It is marked as Taking. C) It is patient-reported. D) It has a “talking person” icon.
A) Its ending date.
True or False: If an order has a recommended “caution sign” field, the user cannot sign the order.
False
True or False: An expired medication will continue to show in the Medication Review section if it is marked Long-term.
True
True or False: In the Visit Diagnoses section, you can associate orders with diagnoses.
False
True or False: To close an encounter, click the X on the patient’s workspace tab.
False
Dr. Mica saw a scheduled patient yesterday. Today, he wants to finish his documentation, but does not see the patient on his schedule. What are possible reasons? (Choose all that apply.)
A) He is looking at a personalized schedule view that does not include his patients.
B) He is looking at today’s schedule.
C) He selected the wrong report in the schedule report pane.
D) He did event tracking on the wrong patient’s appointment.
A) He is looking at a personalized schedule view that does not include his patients.
B) He is looking at today’s schedule.
True or False: Schedule folders under My Schedule are created by users.
True
Hyperspace definition of startup activity
A startup activity is an activity that opens as soon as you log in and that occupies its own workspace. They appear as small tabs in the upper left corner and cannot be closed.
Hyperspace definition of workspace
There are various types of workspaces - pateint, account, and/or administrative - that depend on user setup and the applications your organization has. You can have up to four other work spaces open. Only one workspace can be active at a time. Close a workspace tab by clicking X.
Hyperspace definition of activity
An activity is a module within a workspace where certain tasks are completed.
Hyperspace definition of Widescreen View
A configurable screen that groups related tasks into primary activities.
Hyperspace definition of Navigator
A configurable template that contains a series of sections meant to follow a particular workflow. Allows a clinician to complete a particular task.
Hyperspace term of table of contents
Located at the top of navigator-based activities such as Rooming. In dual-pane navigators, each pane has its own TOC.
Hyperspace definition of toolbar/sidebar
Toolbar - specially designed for performing actions in activities.
Sidebar - Houses activities that are frequently used during the visit.
Hyperspace definition of synonym
Additional name for looking up a choice on a list. Ex: “cxr” is a synonym for chest x-ray
Hyperspace definition of completion matching
Entering partial words. Ex: “poc str rap” or “strep poc” match on “POCT Strep throat, rapid”.
What are some common navigator-based activities used for outpatient
Rooming: Used by nurses to room a patient
Plan: Dual-pane navigator with sections related to placing orders and documenting diagnoses. Used most often by providers
Wrap-Up: Navigator used for finalizing visit charting. Used most often by providers
Encounter
The most common types in EpicCare Ambulatory are Office Visit, Telephone, Letter (Out), abstract, and Orders Only
Medications - Patient-reported
Medications that the patient has reported taking
Medications - Discountinue
Patient no longer needs medication or its not working for him/her. Medication was cancelled and a discontinuationdate entered
Medications - Current
Current medications that the patient is taking. End date is in the future or there is no end date.
Medications - Expired
End date is in the past
Medications - Taking
Depending on the organization, this can mean “Did you take it today?” or “Are you taking this as recommended?”
Medication interaction checking looks to all current
medications, regardless of whether they are marked Taking.
Medications - Sig
Patient instructions for a perscription
Medications - Discrete dispense
In which the dispense amount and refills are calculated based on the duration of the prescription. Discrete dispense does not work if the frequency is “prn,” meaning as needed (ex: Daily PRN).
Medications - Long-term
A long-term medication is considered current after its end date passes, so medication interaction checking continues even after the end date. Also, all the patient’s medications that share the same simple generic medication name are also marked long-term (ex: multiple albuterol asthma medications).
Medications - Discrete Sig
Dose: How much, and what unit? Ex: 500 mg
For weight-based doses (ex: 90 mg/kg/day), the prescribed dose and amount are calculated.
Route: How does the patient intake it? Ex: Oral
Frequency: How often does the patient take it? Ex: 2 times daily
Orders - Summary Sentence
Blue link that shows key details.
Orders - Order Composer
Box of details for a pended order. Used to edit order details. To open, click the order’s name or its Summary Sentence.
Orders - Pended order
Order that is pended and waiting for provider to sign.
Secure and log out
Secure:
- When you are done using this workstation and somebody else will work with this patient’s chart on this workstation.
- The open patient workspace remains open on that
workstation.
- Patient privacy. Beneficial for nurses to do when done rooming a patient so the provider can quickly access the patient’s encounter.
Log Out:
- When you are done using this workstation and nobody will continue with the patient in this room.
- All open workspaces close on that workstation.
- Patient privacy
Pre-charting
Clinicians can use a pre-charting workspace to queue up orders, enter visit diagnoses, and begin notes in an upcoming appointment prior to the patient being marked as Arrived (checked in). All of this is done without converting the appointment to an office visit. If an appointment is canceled or the patient never shows up, the system can automatically delete the data.
Addendum
Allows an audit trail of changes made after the encounter is closed.
Schedule: Personalized view
Located under My Schedule folder, able to create and personalize your schedule view under the general and configuration tab. Able to look up a provider and have it look to all the departments in which that provider is scheduled,
Schedule: Event tracking
Used to indicate that a patient is ready or waiting. Colored flags are used to communicate between users to know the status of a patient.
Schedule: Report toolbar
Toolbar that is setup to be able to access different preferred reports.
Pre-charting versus charting on an arrived patient
Pre-charting:
- Promotes clinicians reviewing important information prior to the visit
- Encourages communication between providers and support staff based on the information reviewed prior to the visit
- Gives clinicians a way to remind themselves and others about specific information they want to discuss with the patient during the visit
- Helps clinicians spend more face time with patients and less time documenting during the visit
- You can control which users can pre-chart and what they can do without converting the appointment
- If an appointment is canceled or the patient never shows up, the system eventually deletes notes and other data that clinicians pre-chart in appointments that never occur
Charting:
- Takes place during and after visit
The relationship among workspace, sidebar, and activities
Workspaces have activity tabs on the left side and at the top of the sidebar on the right side. Sidebars have information regarding the visit, notes and checklists
When to use the magnifying glass in a field
You must use a magnifying glass button to choose an option from the drop down list
When you would mark a medication as long-term and the effects
A long-term medication is considered current after its end date passes, so medication interaction checking continues even after the end date. Also, all the patient’s medications that share the same simple generic medication name are also marked long-term (ex: multiple albuterol asthma medications).
Distinguish between the purpose of, and who uses, the Medication Review section versus the Medications & Orders section
Medication Review: Nurses use this to document the patient’s preferred pharmacy for this visit, review the medication list, and document patient-reported medication such as over-the counter medications.
Medications & Orders: Providers use this section to place new orders, reorder or discontinue prescriptions, cancel orders placed in this encounter.
When to secure versus log out
Secure:
- When you are done using this workstation and somebody else will work with this patient’s chart on this workstation.
- The open patient workspace remains open on that
workstation.
- Patient privacy. Beneficial for nurses to do when done rooming a patient so the provider can quickly access the patient’s encounter.
Log Out:
- When you are done using this workstation and nobody will continue with the patient in this room.
- All open workspaces close on that workstation.
- Patient privacy
When you would exit the patient’s workspace versus close the encounter (sign the visit)
- Exiting the patient’s workspace means that the user can be done with what he/she needed to complete
- Closing the encounter (sign the visit) means that the encounter has been completed, including orders, diagnosis, LOS, etc.
- Usually the provider will be the person to close the encounter by signing the visit
Date Conventions: Today = Week = Month = Year = \+(plus) means -(minus) meas
T W M Y Future Minus
If I will finish my charting later for this office visit, I should…
Exit the workspace
If charting is finished and I want billing to take place, I should…
Close the encounter
