EPIC TUTORIALS FOR IR The following is a tutorial for how to use the EPIC OneChart electronic medical record for your IR rotation. It only includes the basics but will get you off on the right foot and be a good foundation for expanding your EPIC skills. Tutorial for 3 main components are included. – SmartPhrases Obtaining my templates will likely be helpful for efficiency. – Pre-procedure notes – Post-procedure notes and orders

How to obtain SmartPhrases from other users. 1.Click on the Epic icon in the top left corner of the screen. 2.Click SmartPhrase Manager. (To get to Smart Phrase Manager, you may need to go to Epic -> Tools -> SmartTool Editors -> SmartPhrase Manager).

3. Select the User that you want to copy from. Click Go.

4. Double click the SmartPhrase you want to copy. (“H & P” in this case) 5. Click Owners & Users.

6. Click Add Myself. 7. Click Accept.

That’s it. To use SmartPhrases, simply type a period followed by the abbreviation for your SmartPhrase in an open text box. For example, type “.agdhp” to import my H&P template into a blank text box.

PRE PROCEDURE In general, 3 things must be done prior to every procedure. – Obtain paper consent This applies to every patient. – Update H&P or create a new H&P This applies only to outpatients. – Pre sedation screen This applies only to patients who will be getting moderate sedation by our sedation nurses.

How to Update H&P 1.Click Pre-procedure tab once inside the patient folder. 2.Click Update H&P.

3. Find a suitable H&P, consult note, or other note that fulfills all the criteria of an H&P from the list and click Add Interval. You can preview the notes by clicking on the authors name.

4. Select a Cosigner (if you don’t know which staff will be doing a case, just pick any staff that is working that day). 5. Press F2 and select from the drop down box (Changes:22488). 6. Press F2 and select from the drop down box (site marked:22489). 7. Click Accept.

How to make a new H&P If no notes are available to update H&P, you must make a new H&P. What follows is how I do it. 1.Click Notes. 2.Click New Note.

3. Select note Type “H&P”. 4. Select a Cosigner. 5. Type “.agdhp” in the text box to use my template.

6. Press F2 to bring you to the first “***” in my template. Type in the presenting complaint/underlying problem. Something like “cirrhosis and recurrent ascites” would be fine.

7. Press F2 to go to the next “***”. This brings you to the physical exam portion. Delete the “***” and look at the template to see if anything in the physical exam needs to be changed. 8. Press F2 to go to the next “***”. Again, type something brief like “recurrent ascites”. 9. Press F2 to go to the next “***”. Type the procedure here, for example “Therapeutic paracentesis”. 10. Click Sign.

How to make a Pre-sedation Screen note. 1.Click Pre-procedure tab. 2.Click Pre-sedation Screen.

3. Select a Cosigner. 4. You can then press F2 to navigate through and fill in all the required fields in the note. Alternatively you can select all the text in the note (press Ctrl+a) and delete it, and use my template by typing “.agdsedation” in the text box.

If using my template, the Pre-sedation screen note required fields will be already filled in with the most common responses. Look over the note briefly to make sure it is accurate and press F2 to go to the “***” and delete it if no changes need to be made. 5. Click Sign.

Post Procedure After each procedure, 3 things need to be done. – Post procedure Brief Op Note. – Post procedure Orders. – Dictation in McKesson.

How to make a Brief Op Note 1.Click a Post-proc tab. 2.Click Brief Op Notes.

3. Select a Cosigner. 4. Press F2 to navigate through all the required fields and fill in appropriate responses. 5. Click Sign.

How to enter Post procedure orders for outpatients. 1.Click Post-proc Discharge tab. 2.Click Med Reconciliation. This will open a large box in the center of the screen.

3. Click Mark All Don’t Prescribe. 4. Click Mark All Resume. 5. Click New Orders.

6. Click the blue text under Discharge patient. This will open a drop down box. 7. Click Home with No Service. 8. Click the Time box and select an appropriate discharge time (usually after bed rest). 9. Click Accept.

9. Click Interventional Radiology Post-procedure (User). 10. Click Open Order Sets.

11. Check or uncheck the appropriate boxes in the order set. 12. Click Review and Sign.

13. Click Sign – Print and/or E- prescribe NOW.

How to enter Post procedure orders for inpatients 1.Click Manage Orders. 2.At far right of the screen click Order Sets. 3.Now at the center of the screen click Interventional Radiology Post-procedure (User). 4.Click Open Order Sets.

5. Check or uncheck the appropriate boxes in the order set.

6. At the right of the screen you will see your selections. Review them and then click Sign.