Ambulatory nursing job roles at the UIHC may use a variety of Epic activities related to schedules, charge capture, and patient documentation.

Resources

The following documents provide information on Epic functionality used by Ambulatory Nursing positions.

  • Accessing Emergency Drug Lists for NICU & Pediatrics - (Handout) Quickly access the Pediatric and Neonatal (NICU) drug calculator to accurately determine drug dosages.
  • Adult Blood Pressure Checks (AMB900) - (Video: 5 min) Document blood pressure checks using Clinician Communication within Wrap Up and create a Nursing Note for cosign.
  • Adult Blood Pressure Checks (Family Medicine) - (Handout) Nursing workflow to document blood pressure checks and create a nursing note for cosign.
  • Ambulatory Nursing Checklist - (Handout) The Ambulatory Visit Checklist provides a list of items that are essential to complete for each patient in an outpatient encounter setting. The checklist includes links to sections that need to be completed at every visit and links to content that is completed annually.
  • Documenting Patient Immunizations - (Handout) Documentation of immunization history is important to make sure that patient’s medical records are accurate and up to date. This documentation is also important to ensure the recommended schedule for vaccines is correct in Health Maintenance.
  • Editing Patient Goals - (Handout) Providers can edit patient goals within the clinic Office Visit navigator. This helps providers create a collaborative care plan for patients and meet Patient Centered Medical Homes (PCMH) designation.
  • Finding Relevant Information via Storyboard - (Handout) Overview of where to find information in Epic to tell a patient's story.
  • Medicare Annual Wellness Visit Workflow- (Handout) Provides workflow for completion of Medicare Annual Wellness Visit Workflow by nursing staff and providers.
  • Pre-Operative PEC/Social Screening - (Handout) The Presurgical Evaluation Clinic (PEC) and Social Screenings for pre-operative patients help identify important information and additional cares that patients may need to have performed ahead of being seen in the PEC clinic.
  • Tuberculosis (TB) Skin Testing - (Handout) Nursing staff can order the TB Skin Test per protocol.  This tip sheet will review the TB Skin Testing workflow including:  (1) Screening the patient for contraindications, (2) Ordering the TB Skin Test Panel (PPD), (3) placing the PPD, and (4) Reading/Resulting the test.

Labs

Notes

  • Acute Note Types by Role - Grid - (Handout) Epic offers several note types for documenting acute changes in patient condition. Use the appropriate type for your role and area from the grid included here so that other clinicians can easily find your documentation.

Orders

  • Cancel Rx - (Handout) Cancel Rx will electronically send a cancellation message to pharmacies via SureScripts.
  • Electronic Prescribing of Controlled Substances (EPCS) for Nursing Staff - (Handout) UIHC Providers who are authorized to sign controlled substance prescriptions can now send them electronically to eligible pharmacies via SureScripts. The process to send controlled substance prescriptions will mean that providers must provide dual-authentication while signing the prescription. At UIHC, we use Bio-Key fingerprint technology and Epic Login Credentials as our dual-authentication tools.
  • Homegoing DME Orders - (Handout) When a DME order is placed, the DME supplier must be documented via a DME Acknowledgment Task in the Wrap Up activity. The choice of supplier determines what happens next: eSignature, printed form, and/or e-mail and In Basket notifications sent.
  • Outpatient to Emergency Department Referrals for Nursing - (Handout) The Emergency Department Referral (UIHC ED Only) order is used to streamline transitions of care to the ED by relaying pertinent information from the patient's OP visit to ED staff.
  • Placing Per-Protocol Orders via SmartSets for Ambulatory Nursing - (Handout) Order sets are being created for Ambulatory Care Clinics to assist nursing staff place per-protocol orders. As order sets are being created, staff should now use the SmartSets for Per-Protocol orders as they become available.
  • Processing Prescription Medication In Basket Requests for Nursing Staff - (Handout) Patients have many modes of sending initial (new) or renewal prescription medication requests to their care team. The Care Team will begin the process of getting an initial or renewal prescription authorized.

Procedures

  • E-I-S Procedure Navigator - (Handout) The E-I-S activity tab is for documenting Equipment, Instruments, Implants and Supplies used during an outpatient procedure visit. This functionality is designed to bring certain OpTime functionality to areas outside of the OR and provide an easier documenting method.
  • Procedural Sedation Navigator - (Handout) The Procedural Sedation Navigator will appear for areas which routinely perform clinic based procedural sedation.

Radiology Imaging

  • Using CareSelect when Placing Radiology Orders - (Handout) When placing orders for advanced imaging procedures (CT, MR, PET, NM), Epic uses CareSelect to evaluate the appropriateness of the order for that patient. When CareSelect identifies exams that may be more appropriate for the patient, a Best Practice Advisory (BPA) displays with a list of suggested alternatives, allowing you to easily change your order.

Team-Based Care

  • HCC Coding - Nursing - (Handout) HCC coding utilizes International Classification of Diseases (ICD)-10-Clinical Modification (CM) coding to assign risk-adjustment scores to patients. Nursing staff should always review the diagnosis codes and Problem List with the provider prior to documentation of the HCC coding and Assessment and Plan note.
  • Outpatient to Emergency Department Referrals for Nursing - (Handout) The Emergency Department Referral (UIHC ED Only) order is used to streamline transitions of care to the ED by relaying pertinent information from the patient's OP visit to ED staff.
  • Team-Based Care in the Clinic (POSS151) - (Video: 2 min) Learn how the care team can work together during an outpatient visit.

Wrap Up

  • Care Documentation for Ambulatory Nursing - (Handout) The Nursing Care Doc activity ensures complete nursing documentation. This documentation is also used for reporting purposes to determine clinician workload. Clinical Support Staff are still required to document the services and education provided to patients within any other appropriate Epic activities.
  • Nursing Charge Capture - (Handout) Reviews the process for nursing to chart the facility charge for an outpatient visit and send those charges to billing staff for processing.
  • Nursing Charge Capure FAQ - (Handout) FAQ sheet for Nursing Charge Capture function.

Related Pages

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