Videos/eLearnings

• Nurse Writing Notes (INP063) - (eLearning: 2 min) Overview of how to review/create notes and use SmartTools in Epic.
• Writing Consult Notes (MDINP106) - (eLearning: 3 min) Provides an overview of the unique steps for documenting in a consult note.

Handouts

• 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.
• Brief Op Note - (Handout) To support patient safety and meet regulatory requirements, a brief op note describing key elements of all procedures needs to be completed immediately following a surgery.
• Documentation of a History & Physical Pre and Post-Sedation Assessment - (Handout) This document describes how to complete the proper documentation of a History & Physical, an Interval History & Physical, and/or the Pre- and Post-Sedation Assessments in the Epic system.
• Sequestered Notes (Psychiatry Only) - (Handout) Currently users are able to mark an encounter or note as sensitive. When marked as sensitive these notes or visits will not be shared with external entities (via Communication Management, UI CareLink, Care Everywhere, etc.). Sequestered Notes are a subset of sensitive notes. By default, these notes will not be available to other providers and other end users at UIHC (not viewable internally). If granted access, requesters will receive permissions to view the note directly from the HIM Department.
• Worker's Comp Documentation Workflows - (Handout) Documentation for worker’s comp visits have been streamlined to help prevent double documentation. Follow your normal clinic workflows, then when it is time to complete your notes, first complete the Work Summary Patient Status Report (PSR). Key pieces of documentation from the PSR will automatically pull into your Clinic Note via SmartLink.

• Using Documentation from Other Members of the Medical Team in the Billable Note - (Handout) This is the approved workflow when the billable note includes documentation from other members (RN, MA, med/APP students, etc.) of the medical team.
• FAQ - Documentation By Other Members of Medical Team - (Handout) The Centers for Medicare and Medicaid Services (CMS) released new guidance as part of a broader goal of reducing administrative burden on physicians. This change relaxes the Evaluation and Management (E/M) documentation requirements for documentation created by medical students participating in a billable service.