Advanced Charting Techniques for EpicCare Physicians ...

1 Advanced Charting Techniques for EpicCare Physicians :Super Efficiency with SuperPhrasesRevised Edition 2007 Peter G. Churgin, MD, CCFP, FCFPiiAdvanced Charting Techniques for EpicCare Physicians : Super Efficiency with SuperPhrases. Copyright 2007 Epic Systems Corporation. All rights reserved. Printed in the United States of America. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations embodied in critical articles and reviews. For informa-tion, contact Epic Systems Corporation, 1979 Milky Way, Verona, WI, 53593 ( ). After Visit Summary, Epic, EpicCare , Hyperspace, MyChart, and Smart-Forms are registered trademarks or trademarks of Epic Systems Corporation in the United States and/or in other countries. Other product or company names referenced herein may be trademarks of their respective owners.

2 All patient names mentioned in this book are fictitious, and all scenarios described are hypothetical. Any resemblance to real persons or circumstances is purely a coincidence. iiiThis book is dedicated with great affection to my children, Sarah and Daniel, whose love and support have sustained me and whose growth and evolving wisdom are a constant I would like to express my gratitude to the many wonderful colleagues and friends across the nation from multiple organizations who have helped shape this book through contributions of creative new SmartPhrases and SmartLink ideas, through edit-ing and managing the content of those Phrases, and through their considerable software skills to generate the print and HTML versions of this text. Their per-sonal insights and support during the past four years inspired me to create this third edition.

3 I extend my deepest appreciation to them (listed alphabetically by first name): Adam Kiefert, Allan S. Rogers, Andy Wiesenthal, Angel M. Cobiella, Bob Dolin, Brad Eichhorst, Brad Fox, Brian Benz, Bruce Turkstra, Carl Dvorak, Carol Agana, Carole Ecker, Catherine Hernandez, Charlie Selhorst, Claire McCarthy, Clara M. Femiani, Craig Robbins, David Campen, David Lookner, Debra Carl-ton, Donna Deckard, Donna T. Flowers, Erin Stone, Gena Hayes, George Peredy, Grant Okawa, Holly Potter, Homer Chin, Howard Landa, Jason Novick, Jim Shalaby, John Mattison, Jon Darer, Joyce Gil-bert, Judy Faulkner, Karen Woods, Kate Christensen, Laura Johnson-Morasch, Lee Ewin, Liana Passanisi, Loretta Allen, Lori Ridley, Louise Liang, Macy Shia, Marco Lopez, Mark Binstock, Mark Snyder, Michael Miller, Michael Vahldieck, Mike Chase, Mike Krall, Mike McNamara, Milena Ninkovic, Nabil Chehade, Naomi Atkins, Pam Hudson, Patty Graves, Peggy Latare, Peter I.

4 Dwork, Peter Mathews, Ruth Brentari, Sam Butler, Scott Smith, Shawn Hanifin, Stephanie Sales, Stephen Sudler, Steve Bornstein, Steve Cheng, Steven L a ne, Tina Buttner, Thoma s C . Ha r tma n, Va l-erie Fong, Wayne Achterberg, and Wiley Chan. I have also had the opportunity to observe hun-dreds of EpicCare Physicians and nurses in their daily work, and I learned a great deal from their workflows and documentation. I thank them for their contribu-tions, which are reflected throughout the content of the SuperPhrase lest I forget them, let s commend the first medical center to go live with Legacy (forerunner of EpicCare ) in 1993: the medical staff of the CIGNA Chandler HealthCare Center in Arizona. They were the original pioneers, and their fingerprints still linger on every page of this text. vForewordImplementing a complex and integrated electronic medical record (EMR) is not only technically difficult and operationally demanding, but it involves introduc-ing a new documentation paradigm for clinicians.

5 The great technical advance that the EMR has provided for Kaiser Permanente also presents a great challenge for documentation quality and efficiency as clinicians go from pencil and paper to keyboard data are multiple documentation templates or tools in the armamentarium of the EpicCare Ambu-latory application, but none as flexible and modifiable on the fly as SmartPhrases. Dr. Peter Churgin s book on SuperPhrases is full of practical, highly efficient SmartPhrase aids to documentation. EMR documentation requires combining our common words, medical terms, clinical scenarios, medication-use phrases, orderables terms, and Smar-tLinks. SuperPhrases conform to this purpose like no other documentation system, facilitating the docu-mentation of the multi-concern visits so often seen in primary care or the examination room or office, complexity increases with individual needs.

6 From each clinician and from each patient, the medical document needs to reflect information as it is discussed. This is possible with SmartPhrases and Peter s SuperPhrases because they are fully malleable. During our implementation, clinicians have used them mostly as written. Some they changed and con-formed to their personal needs, and some they created from scratch. After working with the different tools in the EpicCare Ambulatory application, multiple cli-nicians continue to support the unique attractiveness and clinical power behind application is fully implemented. Productivity is back to pre-implementation status. And most impor-tantly, our clinicians would never go back to paper, because they could not accomplish the high-quality care achieved without this powerful documentation strongly recommend this documentation system to anyone in the front line clinical practice, be it pri-mary care or the core syntax of the SuperPhrase names will unleash a dramatic potential in your clini-cal electronic documentation, the overall quality of your medical care, and your sense of accomplishment at the end of the office M.

7 Cobiella, MD, MBAC hief of Medical Informatics and Clinical ContentThe Southeast Permanente Medical GroupKaiser PermanenteAtlanta, GeorgiaviviiContentsAcknowledgements .. ivForeword .. vIntroduction .. ixPart 1 Preliminaries on SuperPhrases 1 Introduction to SmartPhrases and SmartLinks for Charting Efficiency ..3 2 The Overture: Common Scenarios for Everyday Use of SmartPhrases ..23 Part 2 The Prefixed SuperPhrases 3 NEG SuperPhrases Negative Review of Systems .. 29 4 NEX SuperPhrases Negative Physical Exam .. 35 5 POS SuperPhrases Positive Review of Systems .. 43 6 PEX SuperPhrases Positive Physical Exam .. 47 7 CV SuperPhrases Complete-Visit Phrases .. 53 8 ALSO or QUICK SuperPhrases ( By the way, Doc, I ve also got a .. ) .. 71 9 IN SuperPhrases Inform, Influence, Inspire: Documenting Your Instructions in Your Progress Note ..75 10 INJURY SuperPhrases Primary Care Musculoskeletal Injuries.

8 83 11 PROB SuperPhrases Problem-Oriented Phrases .. 87 12 SM SuperPhrases for Secure Messaging in MyChart .. 91 13 Master SuperPhrases for Review of Systems and Physical Examination ..93 Part 3 SuperPhrases Without PrefixesIntroduction to Part 3 ..97 14 SuperPhrases for Common English Words ..99 15 Special-Situation SuperPhrases Grammar, Plurals, and Custom Situations ..101 16 SuperPhrases for Common Medical Words and Strings ..103 17 Anatomical SuperPhrases ..107 18 Disease- and Pathology-Related SuperPhrases ..109 19 Scenario-Based SuperPhrases Health Maintenance and Immunization ..115 20 Scenario-Based SuperPhrases Documenting Your Thought Processes in the Plan Section of a Progress Note ..117 21 Scenario-Based SuperPhrases Common Administrative and In Basket Situations ..121 22 Scenario-Based SuperPhrases Office-Visit History and Physical.

9 123viiiPart 4 Workflow-Oriented SuperPhrases for Medications, Nursing, Specialties, and ProceduresIntroduction to Part 4 ..127 Section A Medication-Related SuperPhrases ..129 23 DRUG-Related SuperPhrases Documenting Instructions and Side-Effects to Patients ..131 24 Smart-SIG SuperPhrases Phrases for Order Detail for New Prescriptions ..137 25 Medication-Scenario SuperPhrases ..141 Section B Specialty-Related SuperPhrases ..145 26 Nursing and Telephone-Related SuperPhrases ..147 27 Pediatrics SuperPhrases ..157 28 Obstetrics SuperPhrases ..163 29 Orthopedics SuperPhrases ..171 30 Genetics SuperPhrases ..173 31 Urology SuperPhrases ..179 32 Medical Specialties ..183 Section C Procedure-Related SuperPhrases ..185 33 PROC SuperPhrases for Documenting Your Office Procedures ..187 34 Medical Tests and Office Procedures Based on Scenarios.

10 191 Part 5 SmartLinksIntroduction to Part 5 ..195 35 SmartLinks Some of the Basics ..197 36 Epic SmartLinks ..199 37 ID SmartLink SuperPhrases Patient Identification ..205 38 LastVitalSigns SmartLink SuperPhrases Last Three Available Vital Signs ..207 39 LastLab SmartLinks ..209 40 SmartLink Display Examples from Patient Progress Notes ..215 41 Patient-Instructions (PI) SmartLinks ..231 Part 6 Furthering SmartPhrase and SmartLink Knowledge and Skills 42 Improving Your Efficiency with Keyboard and Mouse Shortcuts ..239 43 Building and Editing Your Own Phrases ..247 44 Refreshable and Protected SmartLinks and SmartLists ..257 45 New SmartPhrase Workflows in the Epic Spring 2006 IU1 Version the HH1 Master File ..261 46 More About SmartLists ..271 47 Getting Past Inherent Limitations of SuperPhrases ..275 Appendix: SmartList Numbers and Names.