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emrepic emr jobaccess pathwayed trauma responsetrauma surgeontrauma surgeon arrival date timeinitial vital signs - full or partialinitial vital signs - consultinitial gcs - full or partialinitial gcs - consulted discharge dispositioned discharge date timeadmit serviceradiologyradiology image start date timeoperation start date timecomorbiditiesadvanced directive imageslegal documentsalcohol usealcohol use tool use and positive thresholdfunctionally dependent health statushome medicationsdelirium tool and flowsheetciwa flowsheeticu daysrooms icurooms floorrooms step-downrooms otherventilator flowsheetdischarge planning notesdischarge date timeblood transfusionplatelet volume or standard pack sizemedication admin date timeopioidswithdrawal of careColumn2
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allscripts sunrise sr: top left corner my applications > acute care / find pt > id > mrn > choose admit date
mrv > triagle ! = to change patient		lev 1 and 2: mrv > trauma flowsheet
consults: sr > docs > consults, orders, ed, h&p		mrv > tfsmrv > tfsmrv > tfs pg 2sr > flowsheets > vs measurement (date range = start of chart / *retain selections for next pt)mrv > tfs pg ___sr > flowsheets > ed assess & care > neuro
sr > docs > ed note, h&p		lev 1 and 2: mrv > tfs pg 4
consults: sr > orders > adm/dc/transf 		lev 1 and 2: mrv > tfs pg 4
consults: sr > docs > ed dispo note 		sr > orders > admit order / sr > docs > ed dispo note sr > results (date range = start of chart / *retain selections for next pt)sr > results > choose report want to view image > click on clipboard icon (see picture)mrv > or reports > anesth fs ("operation" = incision time)mrv > tfs > pt hx pg 1
sr > docs > ed triage note, adm health hx note, nsg adm note, h&p, consults, pn		mrv > adv directive
mrv > miscellaneous		mrv > miscellaneousmrv > tfs > pt hx pg 1sr > docs > ed triage note > past med/social hx
sr > docs > ed triage note > past med/social hx / adm health hx note 		audit c: capture if >= 8 / sr > docs > adult intake formmrv > tfs > pt hx pg 1
sr > docs > ed triage note, adm health hx note, nsg adm note, h&p, consults, pn		sr > docs > ed triage note, adm health hx note, nsg adm note, h&p, consults
sr > outpt med rev (icon at top) *make sure start dates make sense / check "last modified" dates		sr > fs > critical care assess **which tool do you use (i.e., cam)? CAMsr > fs > psychosocialsr > file > registration (at top) > visit location > location hx > chk "assign location"
sr > orders
sr > fs > assess and cares > nursing narrative		ticu, 6icu, ccu, nicu, sicu3s, 4n, 4s, 6n, 7n,7s **can floor beds also be tele? Yes3npc, 5npcsr > fs > resp fs > mech ventilationsr > docs > case manag notes
sr > orders
sr > docs > dc summary
sr > fs > assess & cares > nsg narrative		1. sr > docs > rn dispo note
2. sr > pt info > visit hx		mtp: staff receives email from bld bank (*please provide in dropbox for validators review if applicable)
sr >docs > mtp bld transfusion or bld transfusion		5 pksr > orders > (scroll down) pharmacy (may have to adjust filters at side "no order selection filter") > choose med and right click > view > order task summary (*green chk mark = given)
mrv > tfs
mrv > or reports > anesth fs		*new area for validation starting with 2023 charts > no prior information Outpatient Medication Review > D/C Summarysr > docs > pn, palliative notes
sr > fs > assess & cares > nsg narrative, resp fs
sr > orders > CMO
mrv > gol / brain death
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cernerpowerchart > pt > search > fin > choose datesnotes > Misc pt care > Misc assess (Scanned Trauma Flow Sheet)notes > Misc pt care > Misc assess (Scanned Trauma Flow Sheet)notes > Misc pt care > Misc assess (Scanned Trauma Flow Sheet)1) notes >Emergency Department > ED triage, part 1
2) notes > Misc pt care > Misc assess (Scanned Trauma Flow Sheet)		1) notes >Emergency Department > ED triage, part 11) notes >Emergency Department > ED triage, part 1
2) notes > Misc pt care > Misc assess (Scanned Trauma Flow Sheet)		1) notes >Emergency Department > ED triage, part 11) notes >Emergency Department > ED clinical summary (** hospital policy: pts >= 70 are auto tele when admitted to floor)1) notes >Emergency Department > ED clinical summaryorders, pso admit orderresults review > Imagingresults review > Imaging > exam report (** NO TIME STAMP ON IMAGES > per radiology: time at top of image in ribbon = time imaging started)notes > Perioperative record> intraprocedure> surgery start timenotes > h&p, ed provider, consults1) notes > advanced directive
notes > scanned documents1) Volume base reporting
2) AUDIT/Cage screening & Self reporting		AUDIT Score1) Notes> powerform>case management
2) H&P & Consult notes		1) Notes >Emergency Department > ED clinical summary
2)Notes>ED> physician notes
3)Notes>History and physicial>Trauma H&P
4) EMS records		Notes>assessment view> deliriumNotes>assessment view> CIWAtop menu bar > encounter location history viewertop menu bar > encounter location history viewertop menu bar > encounter location history viewertop menu bar > encounter location history viewertop menu bar > encounter location history viewerresults review > Vitals extended> oxygen therapy notenotes>Discharge documentation>discharge summary
*CM notes are under Notes > Powerform Textual Rendition Notes		top menu bar > encounter location history viewer1) results review > Lab6 pack standardMAROrders, medicationnotes > progress notes
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cernerpowerchart > pt > search > fin > choose datesnotes > ed notes > scanned trauma flowsheet, Trauma H&Pnotes > ed notes > scanned trauma flowsheet, Trauma H&Pnotes > ed notes > scanned trauma flowsheet, Trauma H&P2) notes > triage
1) notes > ed notes > scanned trauma flowsheet		1) notes > triage
2) interactive view > vital signs > change date		2) notes > triage
1) notes > ed notes > scanned trauma flowsheet		1) notes > triage
2) interactive view > vital signs > change date		1) orders, pso admit order
2) notes > ed notes > scanned trauma flowsheet
1) notes > ed notes > scanned trauma flowsheet
2) notes > ed clinical summary > bottom of note
orders, pso admit orderresults review > radiologyresults review > radiology > click into and opennotes > anesthesia final record > surgery start timenotes > h&p, ed provider, consults1) notes > advanced directive
2) notes > scanned documents		notes > scanned documentsvolume base reportingno tooltop menu bar > encounter location history viewerresults review > ventilatornotespt information > visit list > discharge date/time1) results review > lab-extended
2) mtp: scanned documents		6 pack standardmar summarynotes > progress notes
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cernerpre-populated patient list1) cn > ed > trauma > tfs
1) cn > h&p(top)		cn > ed > trauma > tfs > page 1cn > ed > trauma > tfs > page 11) cn > ed > trauma > tfs > page 4 (grid)1) cn > ed > triage
2) cn > ed > ed provider		cn > ed > trauma > tfs > page 11) cn > ed > triage
2) cn > ed > ed provider		1) cn > report summary > ed throughput
2) encounter location viewer
3) cn > h&p
1) cn > report summary > ed throughput
2) Orders > Admit/Transfer/Discharge > Bed report
3) encounter location viewer
cn > h&presults review > radiology results review > radiology > click view image icon > scout time1) cn > intra-op > surg start time
1) cn > anesthesia records		notes > h&p, ed provider, consults1) notes > advanced directive
2) notes > scanned documents		notes > scanned documentsvolume base reportingcn > H&P >CAGE Assessment (positive score = 2 or more yes responses)cn > pt/ot1) cn > all notes
1) orders > doc med by history		flowsheet > asses tab > camflowsheet > asses tab > ciwn1) orders > change of care order
2) top menu bar > encounter location history viewer		ICU 28-1 through 28-24; CVICU 29-1 through 29-135E 500-516, 5W 521-544, 3E 3128-3141, 7E 701-717CPCU 29-14 through 29-34CDU 440-460results review > ventilatornotespt information > visit list > discharge date/time1) flowsheet > lab tab > blood bank and transfusion > look for issue time
1) cn > lab > scanned
1) tfs
1) anesthesia flowsheet		5 pack standardmar summarycn >Discharge Documentation > DC summary -OR- Orders > Medications > Medications with Prescribed Statusnotes > progress notes
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cerner1) full /partial: clin docs > acute care > emerg dept note / data (2) clin docs > acute care > H&P or emergency treatment note1) full /partial: clin docs > acute care > emerg dept note / data (2) clin docs > acute care > H&P or emergency treatment note1) full /partial: clin docs > acute care > emerg dept note / data (2) clin docs > acute care > H&P 1) full /partial: clin docs > acute care > emerg dept note / data (2) results review > vital signs1) Forms > ED triage note 2) results review > vs1) full /partial: clin docs > acute care > emerg dept note / data (2) results review > documentation > gcsresults review > documentation > gcs1) forms > ed pt dispo > exit time (if exit time blank, use time note entered) (2) pt info > encounter location history1) forms > ed pt dispo > exit time (2) pt info > encounter location historyH&P, power ordersclin docs > diagnostic results > radiology or results review > radilogy clin docs > diagnostic results > radiology or results review > radilogy > view image icon top left1) clin docs > surgical invasive procedures > or nursing records > intra op nursing record (2) clin docs > surgical invasive procedures > anthesiaclin docs > acute care > H&P, ed notes, consults, dc summary, progress notes / histories > past medical, social history / clin docs > pt care support servicesscanned: may be under clin docs > medicolegal / clin docs > pt care support servicesclin docs > medicolegal1) clin docs > acute care > Trauma H&P / (2) histories > social history / (3) clin docs > pt care support services (sw / cm notes)1) clin docs > acute care > Trauma H&P / (2) histories > social history / (3) clin docs > pt care support services (sw / cm notes)clin docs > medicolegal / clin docs > pt care support services (PT/OT/CM notes)clin docs > acute care > H&P, ed notes, consults, dc summary / medlist > med by history > rec history > admin and dc medsforms > delirium / results review > documentation >delirium screeningpower orders > transfers/admits / Encounter Location Historyresults review > vital signs clin docs > pt care support services1) Face Sheet / 2) overview > encountersClin doc > Transfusion Record5 packmar summary / anesthesia form / clin docs > acute care > Emerg dept note / dataPower Orders / medication listforms > extubation / clin docs > pt care support services / clin docs > acute care > progress notes / power orders
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epicpt station > mrn > choose correct admission date > open chartchart review (cr) > ed pt care timeline / h&p1. cr > ed pt care timeline > staff arrived
2. cr > h&p		1. cr > ed pt care timeline > staff arrived
2. cr > h&p		cr > ed pt care timeline / vs flowsheetcr > ed pt care timeline / vs flowsheetcr > ed pt care timeline cr > ed pt care timelinesummary > adt events / event management summary > adt events / event management 1. h&p
2. adt events/event management, H & P		cr > imagingcr > imaging > pax imaging (may have to scroll through images)rep viewer > case tracking events > case starth&p, consults, ed prov notes, pt snapshot, progress notes, EMS pre hospital record cr > media / (emr side area) code / directives > click oncr > media 1. H&P self reported
2. serum volume
3. audit c
4. summary >patient profile
5. snapshot
6. progress notes		audit c (in notes and fs) > positive score greater than 4, also on the tertiary survey h&p, consults, ed prov notes, pt snapshot, progress notes, summary>pt care profile, pt/ot, case management, ems report, ed patient care timelineindex > home meds > pta meds / med hx, H&P, progress notes/consult notes, ems reporting, snapshot, chart review>medsnotes / cam (search cam in fs)search ciwa in fs > go to dateevent management > click into lines to see locfs > critical care / LDA or respiratory flowsheetcm notes, dc summary, ordersevent management / adt eventsed timeline, anesthesia record, fs > bld admin tab, fs > i&o, media > scanned forms, index > bld admin > encounter
***MTP > lab sends reports that are not scanned		6index > meds given / index > mar (green = given), ed pt careline, anesthesia fsdischarge summaryprogress notes, orders, lda fs for extubation times
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epic1) pt station > enter mrn > change to all > on top > open chart
2) ed chart		trauma patient care timeline > staff arrived > level 1 = full h&p > initial evaluationh&p > initial evaluation > response date/time1) patient care timeline
2) summary > ip nursing index		1) patient care timeline
2) summary > ip nursing index		1) patient care timeline
2) summary > ip nursing index > neuro assessment		1) patient care timeline
2) summary > ip nursing index > neuro assessment		1) patient care timeline > "admitted" (need to confirm care delivery in orders for tele, etc.)1) patient care timeline > "admitted" h&pchart review > imagingchart review > imaging > "show patient images" > in green writing on left hand side "primary" is date/time > pull timestamp inpatient nursing index > anesthesia record > incision date/timeprogress notes, h&p, consults, ed provider noteschart review > media > advanced care planning or osh records1) media1) patient care timeline 2) index > inpatient all flowsheet > risk assessment
cage >= 8 positive for female -this is frequency
cage >= 15 positive for male-this is frequency
CAGE score >= 2 questions answered "yes" = positive acohol use, M or F		pt/ot notes, H&P-PMHh&p, consults, anesthesia record, rehab notes, internal med notes or inpatient nursing index > pta med reconciliation1) Flowsheets>Assessment>Geriatric CAM Assessment
1) IP Index Nursing > Inpatient Accordian > CAM		summary>ip nursing index>Risk Assessment1) accordion hospital billing > events > accomodationC 3WCCU, C 7NSICU, H 6SICU, H 2N2S PEDS (Regular, Mod Care & PICU combined unit)All other Units are non ICU beds1) ards accordion
2) lda		1) account summary > discharge info
2) adt info		epic dropdown > hospital account maintenance1) blood admin report
1) patient care timeline
1) flowsheet > blood tab > uncheck completed
1) chart review > media > blood transfusion (MTP)		5 pack standard1) vte prophylaxis: inpatient index > anticoagulation accordian
2) abx: inpatient index > antimicrobial summary
3) other drugs: inpatient nursing > mar report		Chart Review>Meds Tab>Uncheck "Current Meds Only">Opioid (should have "AMB" next to it on or near DC date)chart review > progress notes, orders, respiratory care, or other orders
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epicpatient station > mrn1) halo (phone app) > upload to dropbox prior to visit
2) chart review > choose encounter > master report at top > edtl > "trauma start"
3) chart review > notes > h&p top of document		1) chart review > edtl > "staff arrived"
2) h&p top of document
3) ed provider note > "trauma at bedside"		1) chart review > edtl > "staff arrived"
2) h&p top of document
3) ed provider note > "trauma at bedside"		summary > ed vitals or edtl > flow sheets summary > ed vitals or edtl > flow sheets summary > ed vitals or edtl > flow sheets summary > ed vitals or edtl > flow sheets chart review > other orders > admit to inpatient >edtlchart review > other orders > admit to inpatient >edtlchart review > other orders > admit to inpatient >edtlchart review > imagingchart review > imaging > "show patient images" > hover over timeline at top on correct image > pull timestampencounter > surgery > case tracking events > case start date/timechart review > h&p, consults, ed provider, progress notes, anesthesia pre-op note1) chart review > media
2) demographics menu > adv directive > click adv directive		chart review > media1) chart review > h&p
2) chart review > notes > assessments > near h&p > audit		Audit > 7 male is positive
Audit > 6 female is positive		H&P or consult notes1) chart review > H&P
2) chart review > medications tab > uncheck "Current meds only" box
3) geriatrics consult note 4) discharge summary 5) pharmacy note		flowsheets > critical care adult > cam-icu screeningflowsheet> search (magnifying glass on R) > CIWA score1) other orders > see bottom of order for level of care and special facilities
2) other orders > "transfer patient to new unit order"		25 icu = step-down or icu42 = neuro checks q2 or floor25 can also be stepdown (Patient Station, scroll to appropriate encounter, Event Mgmt)17 or 32 = OBS, 44 = Orthoflowsheet > complex assessment1) case manager or social worker
2) chart review > other orders > discharge
3) discharge summary		1) hover on left to show time
2) encounter > timeline on the right		results review > blood bank > click transfused > "status of unit"5 in a pack standardchart review > meds > uncheck current meds > open event history > complex scheduler history Encounter > magnifying glass in R corner > Type "AVS" (don't hit "enter") > select Audit Trail: AVS under Summary > Opioid Start Talking Form (IP After Visit Summary on same page would be back-up option)1) chart review > other orders
2) notes
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epicpatient stationfull/partial: chart review > media > trauma > tfs > page 1 top
upgrade/downgrade: chart review > consult or h&p or ed provider > hpi
consult: h&p or consult		chart review > media > trauma > tfs > page 1 topchart review > media > trauma > tfs > page 1 topfull/partial: chart review > media > trauma > tfs > page 2 middle
if inhouse activation, then look at flowsheets		consult: flowsheets > vitals tabfull/partial: chart review > media > trauma > tfs > page 2
alternative would be page 4 grid or verbiage page		consult: summary > flowhseets > basic assessment tab or pt care timeline or ed providersummary > overview > adt events and Chart Review> other orders > admit to inpatientsummary > overview > adt eventssummary > overview > adt events or other orders > admit to inpatient > blue hyperlink> bottom of notechart review > imagingchart review > imaging > bottom for "exam begun" and use PACS times by click on blue hyperlink at topchart review > notes > Op note > time at top of noteh&p or ED notes
consults
summary > medical problems 		chart review > media > "advanced directive" or " external"chart review > mediaChart review > notes> H&P, addiction med notes, social work, ED noteaudit cchart review > notes > PT/OT notesh&p
dc summary
summary > reviewed prior to admission medications		flowsheet > basic assessment > camflowsheet > ip ciwa-ar score summary > overview > adt events summary> overview > adt events (ICU rooms are 3500's)summary> overview > adt events summary> overview > adt events (Step down 3400's)flowsheets > vent docchart review > notes > care management (author)summary > overview > adt events and Chart Review> other orders > discharge patient1) chart review > icon tab > transfusion > encounter
2) chart review > media > blood transfusion sheets
3) chart review > media > tfs (not the best) 4. Chart review > other orders > blood transfusion listed		plt: 5 standard1) chart review > meds > encounter filter > therapeutic class > anticoagulants
2) summary > index > anticoag
3) chart review > mar > mar report 4. Chart Review > icon tab > ED Med Admin		1) chart review > notes > discharge note 2) Chart review > Meds > discharge date and opioid prescribed1) progress notes
2) rn notes
3) sw notes
4) spiritual care
5) pallative care
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epicED Charge Secretarypatient station > mrn1) Vocera (phone app) > upload to dropbox prior to visit
2) chart review > patient summary > Trauma Summary > scroll down to 'Trauma Activation Level'
3) chart review > patient summary > ACS Summary-Narrator: Trauma Flowsheet		1) h&p signer/co-signer
2) chart review > patient summary > All ED Notes		1) Full activations: hospital badge-in report to be uploaded to dropbox
2) Partial activations: h&p - provider documention
3) chart review > patient summary > All ED Notes		trauma summary > scroll down to 'Vitals' or edtltrauma summary > scroll down to 'Vitals' or edtltrauma summary > scroll down to 'Vitals' or edtltrauma summary > scroll down to 'Vitals' or edtlchart review > other orders > admit to inpatienttrauma summary > scroll down to 'ADT Events' > use first 'OTFADMIT' time if listed1) service authoring H&P
2) chart review > other orders > admit to inpatient		chart review > diagnosticschart review > diagnostics > click link "show images for ..." > use "Study Date:" & "IM Time:" in the top right corner of imagetrauma summary > click link "Case Tracking Events Only" > incision startchart review > h&p, consults, ed provider, progress notes, anesthesia pre-op note1) chart review > Scans
2) demographics menu > adv directive > click adv directive		chart review > Scans1) chart review > h&p
2) chart review > notes > assessments > near h&p > audit
3) notes > SW notes		Audit > 7 male is positive
Audit > 6 female is positive		1) chart review > notes > SW initial assessment (DME use)
2) chart review > notes > PT/OT
3) H&P; consult notes		1) trauma summary > click "PTA Meds" link
2) chart review > H&P; Hospitalists consult note
3) chart review > medications tab > uncheck "Current meds only" box
4) Anesthesia record		1) flowsheets > Adult Assessment > Neurological > 3D CAM
2) flowsheets > critical care adult > cam-icu screening		flowsheets > CIWA-Ar Alcohol Withdrawal Assessment1) trauma summary > ADT Orders
2) other orders > see bottom of order for level of care and special facilities
3) other orders > "transfer patient" order		25 icu = step-down or icu42 = neuro checks q2 or floorflowsheet > invasive vent1) case manager or social worker
2) chart review > other orders > discharge
3) discharge summary		1) encounter > timeline on the right
2) trauma summary > scroll down to 'ADT Events'		1) MTP: scanned documents
2) chart review > All ED Notes
3) trauma summary > click "Blood Transfusion Record" link		5 in a pack standard1) MAR > Report
2) chart review > meds > uncheck current meds 		chart review > Encounter > "Medication List at Discharge"1) chart review > other orders
2) notes
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epicTrauma Registry1) click wrench under “patient list”
2) on “available lists” click “mtqip validation list”
3) click arrow to migrate to “active lists” column
4) click “ok”		1) Snapshot > Trauma Timeline > Trauma Activation > Level One (Trauma Code), L2 (Limited)
2) ED provider Note or Trauma Surgeon dictation = HPI		1) Snapshot > Trauma Timeline > Staff Arrival
2) notes review > h&p/consult note		1) Snapshot > Trauma Timeline > Staff Arrival
2) notes review > h&p/consult note		1) Snapshot > Trauma Timeline > Vital Signs
2) Flowsheets > Vitals > Go to Date > arrival date/time		1) Snapshot > Trauma Timeline > Vital Signs
2) Flowsheets > Vitals > Go to Date > arrival date/time		1) Snapshot > Trauma Timeline > Vitals
2) Notes > ED Provider Note		1) Notes > ED Provider Note
2) Snapshot > Patient Care Timeline		1) Snapshot > Trauma Timeline> Trauma Outcome
2) Summary > Overview > ADT Events
1) Snapshot > Trauma Timeline> Trauma Outcome
2) Summary > Overview > ADT Events
3) Encounters > Current encounter > Care Timeline		1) notes review > h&pImagingImaging > show images (hyperlink) > timestamp on topogramEncounter > associated Anesthesia Event > Events > Procedure startnotes review > h&p, consults, ed notes, progress notes1) Search bar > advanced directive
2) Demographic box on left by name/picture> Code > documents		1) Search bar > advanced directive
2) Demographic box on left by name/picture> Code > documents		Summary > Index > All flowsheet documentation > psychosocial review > Audit C Alcohol Screening audit-c, >= 7 positive resultNA - Not collected anymorenotes review > h&p, consults, ed notes, progress notesFlowsheets > Complex Assessment > Delirium Assessment > CAM-ICU/NuEDSCFlowsheets > search by wrench > CIWA-Ar ScoreSummary > Overview > ADT EventsICU = M5xx3rd - 10th, except for 5 (icu) & 6 (stepdown)6th (stepdown)2nd = rehab, UCU = observation1) Vent days = Chart review > LDA > uncheck hide inactive LDAs > ETT days and/or surgical airways (if trach = use notes)
2) Flowsheet = Complex Vitals > Oxygen Therapy		Chart Review > Notes > Case management notes, progress notes1) Encounter > Care timeline
2) Summary > Overview > ADT events		1) Summary > Index > Significant Events > Blood Transfustion > Encounter
2) Chart Review > Media > Blood documentation (for paper blood documentation i.e. MTP/Emergency Release
3) Summary > Trauma Timeline > Blood transfusion, MTP, nursing note		6pk platelets, 300 mlChart Review > Meds > Filter by med > click med > Full administration report > Action time1) Chart Review > Encounter > Expected Medication List at Discharge
2) Chart Review > Meds > check current meds only > Ambulatory medications listed		notes review > rn, multidisciplinary
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epicemergency rnpatient station > mrnsnapshot > trauma document timeline1) snapshot > trauma document timeline 2) ed summary > ed patient timeline 3) ed summary1) Trauma note 2) Snapshot > trauma document timeline1) snapshot > trauma document timeline 2) ed summary > ed patient timeline1) snapshot > trauma document timeline 2) ed summary > ed patient timeline1) snapshot > trauma document timeline 2) ed summary > ed patient timeline1) snapshot > trauma document timeline 2) ed summary > ed patient timeline1) summary > event log > patient movement 2) event management1) summary > event log > patient movement 2) event managementh&pchart review > imagingchart review > imaging > click into pacschart review > encounters → Surgery → Intraprocedure Summary1) summary > problem list 2) previous admissions 3) chart review > h&p, consults1) left side of screen > code status 2) chart review > mediachart review > mediachart review > sw notesnavigators > audit c value >= 7 is positivenavigators > ed > adls1) navigators > home meds/history flowsheet > basic assessment > delirium/camflowsheet > basic assessment > ciwaevent management2S, 3S4S, 5S, 6S, 7S (all can have tele)2N (inpatient rehabilitation)flowsheet > ventilator documentation/complex vital signs1) chart review > sw/care management notes 2) summary > event managementevent management1) summary > index > blood transfusion 2) encounter > anesthesia flowsheet5 standard pack sizesummary > index > medication summary > medication givenChart Review → Meds. Or Chart Review → Media → After Visit Summary (AVS) 1) chart review > progress notes, palliative care consults 2) lda 3) orders 4) chart review > media > scanned physician orders > code blue
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epiced rn and transportpatient stationcr > notes > h&p > top of note1) cr > notes > h&p > top
2) ed timeline
3) summary > ed trauma doc > "trauma staff"		1) cr > notes > h&p > top
2) ed timeline
3) summary > ed trauma doc > "trauma staff"		1) summary > pt care timeline
2) summary > comphensive flowsheet		1) summary > pt care timeline
2) summary > comphensive flowsheet		1) summary > pt care timeline
2) summary > comphensive flowsheet
3) notes		1) summary > pt care timeline
2) summary > comphensive flowsheet
3) notes		adt events > level of careadt events > level of carecr > other orders > admit orderscr > imagingcr > imaging > show imagescr > anesthesia > events on right1) h&P
1) consults
1) ed provider		chart review > mediachart review > mediaaudit c>= 3 positive female, >= 4 positive malept/ot notes1) summary > index
1) h&p
1) summary > encounter > home rx		1) cam: summary > nursing > flowsheetsummary > nursing > flowsheet > search "risk"
event manager > level of care1) cr > lda's
1) rn index > resp accordian > verify using procedure notes
chart review > case management
notes > progress > case management		adt events1) media > "paper chart"
2) blood accordian > blood admin facesheet
3) cr > labs > check blood bank box
*rr > transfused is old and has issues
6 standard1) summary > mar tab > green = given, black = stoppedcr > media > IP After Visit Summaryhospice notes
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epicpatient station1) full/partial: summary > pt care timeline > trauma classification
2) full/partal: use notes top if not avail
1) consult: trauma consult		1) pt care timeline > staff arrived
2) summary > flowsheets > trauma attending response
3) cr > notes > tpm entered and md signed		1) pt care timeline > staff arrived
2) summary > flowsheets > trauma attending response
3) cr > notes > tpm entered and md signed		1) summary > pt care timeline
2) summary > comphensive flowsheet
3) md note 		1) summary > pt care timeline
2) summary > comphensive flowsheet
3) md note 		1) pt care timeline
2) ed provider		1) pt care timeline
2) ed provider		summary > pt care timeline > pt admitsummary > pt care timeline > pt admit1) summary > pt care timeline > bottom near order
2) chart review > other orders > uncheck box		1) chart review > radiology
2) results review		1) chart review > radiology > show images > pull scout time
2) results review		Surgery tab>case/surgery date > scroll down to find time1) chart review > encounter>surgery date>anesthesia event>scroll down to detailed anesthesia report; 2) anesthesia note and OP note 1) all notes1) chart review > media
1) left menu bar		chart review > mediavolumeno toolpt/ot notes1) h&p
1) dc summary
1) all notes		1) cam: summary > comprehensive flowsheet
1) notes - geriatrics		maws fs: summary > comprehensive flowsheet > adult ip fs > above the icu liberation bundle
patient station > level of caresummary > flowsheet at topchart review > case management
notes > progress > case management		patient stationed blood = summary > pt care timeline
or blood = encounters > anesthesia event /
floor blood = rn flowsheet > blood (intake/output tab also includes OR blood often)
mtp blood = progress note rn > blood note or
chart review > transfusion or media tab
results review > blood products > p = given (use as a guide since it includes survival flight)		5 standard1) mar
1) anticoag tab
1) heparin = OR / encounter > anesthesia event		1) discharge summary 2) Medication tab 3) After visit summary1) progress notes
1) rn notes
1) sw notes
1) spiritual care
1) lda
1) orders
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epicpt station > mrnlev 1 and 2: summary > acs trauma report
consult: ed provider note / h&p		chart review > media > trauma team signaturechart review > media > trauma team signaturesummary > acs trauma report / ed pt care timelinesummary > acs trauma report / ed pt care timelinesummary > acs trauma report / ed pt care timelinesummary > acs trauma report / ed pt care timelinesummary > ip phys index > ed enc summary > adt timeline (click on date to see level of care)summary > ed pt care timeline "pt admitted" = time
summary > ip phys index > ed enc summary > adt timeline		h&pchart rev > imagingpacs image viewchart rev > encounter > anesth recordchart rev > notes > h&p, ed prov note, consults, etc.chart rev > media > adv dirchart rev > mediachart rev > notes > h&p, ed prov note, consults, sw notes, pn, etc.audit score >6 = capture (unless contradicted in other charting)chart rev > notes > h&p, ed prov note, consults, sw notes, pt/ot notes, pn, etc.chart rev > notes > h&p, ed prov note, consults, etc
chart rev > med tab
summary > ip phys index > all current meds > outpt meds		fs > Scoring Scales > rass / cam icufs > Scoring Scales > sewssummary > ip phys index > ed enc summary > adt timeline (click on date to see level of care)summary > ip phys index > comp fs
summary > ip phys index > ed rn assessment		summary > bgh him coding > dc infosummary > ip phys index > ed enc summary > adt timelineblood bank
chart rev > media > transfusion
summary > acs trauma report > trauma intake
chart rev > encounter > anesthesia
summary > index > bld transfusion or Flowsheets > Blood admin > Transfusion Report 		volume summary > ip phys index > med hx (green = given) or Summary > IP Index Nurse > Medication History Discharge Summary Note / After Visit Summary > or Media tab > Opioid start talking chart review > notes
orders
extubation times or "click" code status on left hand side to see when Comfort care order was placed
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paragonenter mrn top left text box > find a patient1) trauma > top left circled 2) ed record > page 11 > trauma level 3) ed record > page 4 > trauma level 4) h&p 1) trauma 2) ed record > page 11 > trauma staff 1) trauma 2) ed record > page 11 > trauma staff 1) trauma 2) ed record > vitals (do not use trauma full vitals within 30 min since lacks timestamp)1) trauma 2) ed record > vitals (do not use trauma full vitals within 30 min since lacks timestamp)1) trauma 2) ed record > gcs1) trauma 2) ed record > gcs1) ed record > page 1 2) top blue "i" next to facility > room and bed (or is not listed) 3) clinical care station1) ed record > page 1 2) clinical care station1) facesheet 2) top blue "I" next to facility 3) h&pradiologyflowsheet > results > radiology image dialogue box > click image iconanesthesia flowsheet h&p, consults, progress notes, rn notes, osh records, care management notes1) global 2) h&pno toolh&p, home medications, consults, ed record clinical care station > daily assessments > search for cam clinical care station > daily assessments > search for ciwa 1) orders > level of care changes in icu orders for floor status 2) clinical care > daily focusclinical care > vital signscare mgmt dc planning1) top bar discharge date 2) order stop date/time1) transfusion > form or reconciliation sheet 2) anesthesia flowsheet 5 pack standardmedication administration > med admin history report > admindischarge summary phys doc > under discharge medications1) progress notes 2) orders
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