Notes are primarily created to document information related a patient’s care and communicate with other care providers. Many different types of notes are used to document a variety of information from consults, to procedures, clinic visits, discharge summaries, critical events and more. Notes may also be generated from within a variety of Epic activities such as the Notes activity or a workflow navigator. Additionally, notes must be created and/or modified within the related patient encounter.

Resources

The following resources provide information on Notes functionality.

General Resources

  • Addending a Note - (Handout) New information about a patient may require an addition or change to documentation after a note is signed. Addending a note allows staff to update the note in these cases. After signing an addendum, notes appear with status Addendum in Chart Review.

  • Attribution Information in Notes - (Handout) For notes where attribution information is available, an attribution popup window will display enabling the user to see details about who authored which portions of the note, the origin of the text, and other details. Attribution information may appear in various places where notes display throughout Epic (e.g. Chart Review activity, Notes activity, etc.).

  • Automatic Note Routing with Communication Management - (Handout) To help increase communication between providers, Epic will automatically route communications, including certain note types (excluding psychiatry), to PCPs, referring providers and the patient’s care team, including external providers. Based on the recipient’s preference, communications will automatically send to their In Basket, fax, or print to a department defined printer to be mailed. Communication Management will function differently between Inpatient and Outpatient encounters.

  • Basic Note-Writing in Epic - (Video: 17min) Walks through the basic steps of writing a note from selecting the encounter to completing and signing the note. Also reviews the Notes activity, basic Epic SmartTools, and addendums.

  • Copying Previous Notes - (Handout) This document shows you the approved method to copy previous notes in accordance with UIHC policy.

  • Correcting Notes on the Wrong Encounter - (Handout) When a note has been attached to the wrong encounter, it can be corrected using one of three workflows: copy/paste into a new note, copy previous into a new note, or move the note.

  • Cosigning Notes - (Handout) When staff members create a new note, they can add a cosigner to review and provide feedback on the note. Once a cosigner is chosen, and the note is written and signed, it is sent to the cosigner’s In Basket for final review. These notes show a status of “Cosign Needed” in Chart Review until they are signed by the cosigner.

  • Documentation of Patient Misconduct - (Handout) Document patient misconduct toward a clinician utilizing the new patient misconduct Note Tag and SmartPhrase. Capture information for unique patient/clinician encounters where misconduct has occurred due to social identity.

  • Inserting Images into a Note - (Handout) Epic allows users to insert images into their notes. The image must be scanned or uploaded into the patient’s chart before it can be attached to a note.

  • Marking a Note as Sensitive - (Handout) Patient records, including notes, can be shared externally. Clinicians, at the request of the patient, or when they deem it necessary, can mark a note as ‘Sensitive.’ Marking the note as ‘Sensitive’ will prevent the note from being viewed by outside healthcare entities. Sensitive notes will still be viewable in Epic to end users at UIHC and to the patient in My Chart.

  • Note Writing Basics - (Handout) There are several methods available for writing notes, and each one has unique advantages. For that reason, many staff use a combination of methods depending on the length, level of detail, uniqueness of the note, and availability of note type. Has your department switched to using NoteWriter? Click here for Note Writing Basics - Creating Notes Using NoteWriter.

  • Overview of Writing Notes (CLN055) - (eLearning: 10 min) Write notes using Epic's stardard Note tools, including SmartTools and NoteWriter.

  • Personalizing Notes (POSS019) - (Video: 1 min)

  • User Dictionary (POSS022) - (Video: 1 min) Learn how to use shortcuts to enter common and often misspelled words using the User Dictionary.

Goals of Care/Code Status

  • Documenting Patient Code Status and GOC Conversations - (Handout) During the September 2019 UIHC Joint Commission full hospital survey, some patients with DNR or Other code statuses were found to lack documentation of provider and patient/family conversations. Documentation of conversation should be available to all care providers in Epic and is required.

Note Types

  • 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.

  • Writing Consult Notes (MDINP106) - (eLearning: 3 min) Provides an overview of the unique steps for documenting in a consult note.

Role & Department-Specific Note Workflows

  • ED Notes (LIP Workflow) - (Handout) Quick buttons allow you to begin the type of note you need with only one click. These can be accessed through the My Note activity.

  • Nurse Writing Notes (INP063) - (eLearning: 2 min) Overview of how to review/create notes and use SmartTools in Epic.

  • 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.

Student Guidelines & Workflows

  • 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.

  • 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.

Related Pages

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