Epic Guide

Admitting a patient

Use Admission tab in Epic

• If patient presents with acute stroke:

  • NIHSS - fill in the stroke scale

  • Stroke documentation - note times during the stroke code so that you can document them here

• Select Med rec (pt on unit)

  • Reconcile home meds - ensure that patient's prior to admission medications are accurate and select which ones to continue or hold.

  • Review current orders - select which orders to continue from the ED or prior unit and which to discontinue

  • Order sets - select appropriate admission order set (Stroke w/tPA, stroke without tPA, general neurology) and review orders within the order set to ensure that they are appropriate for your patient

  • Within the admission order sets, you will have the option to add your patient to an inpatient neurology list (see 'Patient Lists' section below)

• Make sure you put in admission diagnoses as this is how the hospital gets paid. You will not be able to enter orders once a patient is admitted if you did not select/enter at least one hospital problem in the problem list

• Medication ordering:

  • Be careful of the start time of medications – the default in many cases is to dispense a dose at the time of the order, which may result in double dosing.

  • If the order button does not let you transfer an inpatient medication, try the replace button to find an alternative. If there is no alternative, don't order and the patient can take their own medication if they have it. Inform the pharmacy and nurse and enter a nursing communication.

• H&P Notes: Use smart text for "Neuro Note" or "Stroke Admission Note." F2 to advance to the next required field. Any documentation already entered (such as for stroke patients) should autopopulate in your note.

Daily Orders

• Labs ordered for “Daily AM draw” are scheduled for 0600 on the floors, and 0100 in the ICUs, though actual collection time may vary by 1-2 hours in each direction. Keep this in mind when ordering time-specific labs.

• Review and discontinue unnecessary ICU orders/labs whenever a patient is transferred from NSICU to the floor or stroke unit; and ideally daily. This helps anyone reviewing the patient's orders to understand them, and the plan of care.

• Daily medications default to being given at 1000, and BID medications at 1000 and 1800. “Q12H scheduled” is a useful option for AEDs (10 AM and 10 PM), and custom schedules are the easiest/best way to order meds that require strange dosing schedules (i.e. Sinemet)

• If it is necessary to print a prescription PRIOR to discharging a patient (i.e. for assistive devices provided in-house, or if prescriptions are filled through charity care), complete the discharge med rec and/or enter new orders in the Discharge activity (see below) and sign them to print the scripts; however in this case, do NOT add the neurology discharge order set until it is time to actually discharge the patient.

Discharging a patient

Note: All orders entered in “Discharge to Mount Sinai” tab will be signed and HELD – these are meant to be released if desired by the receiving service (generally PM&R). Medication and order reconciliation can be done here, but do NOT enter the Neurology Discharge order set here as it will not be activated!

Discharges to home, outside acute rehab, SAR, or SNF:

• Select Discharge tab -> Med Reconciliation

• Confirm Home Medications with patient if not done during admission

• Reconcile Meds for Discharge: decide what to continue, hold, or replace.

  • This must be accurate because these medications will be provided to the patient/facility as part of the discharge documentation.

  • For patients being discharged to a FACILITY where prescriptions are not necessary, choosing “Historical Med” or "No print" under class to avoid having to send the script to a pharm cy. Still ensure that the dose/route/frequency are entered correctly, however.

• New Orders for Discharge: Neurology Discharge Order Set

  • Must be completed on ALL discharges; items are mostly self-explanatory. Follow-up appointments can include a specific provider (if known) or Clinic and the specific clinic in which they will follow-up. Note: “Chart Review” activity -> “Encounters,” and unchecking “hide additional visits” will reveal future scheduled appointments.

  • Additional orders: these include medications not started as inpatient, PT/OT referrals, outpatient imaging/studies, and outpatient labs. Order “RX (LAB/RAD)” to create a blank script for free-text orders.

• Discharge Summary – this can be completed through the discharge tab, but may be easier from “Notes” tab to allow referencing of other areas of the chart.

• Discharges to MSH Acute Rehab, MSH Inpatient Psychiatry, or VNS Hospice - these are considered full DISCHARGES and require the same discharge orders as above.

• Sign your discharge orders on the unit where the patient is located – this will ensure that any paper prescriptions are printed in a location where you can find them

• Note: “Discharge to Mount Sinai” only creates held orders to be released on readmission.

• After signing discharge orders, click on “Preview AVS” in the discharge tab – red text at the top will tell you any items that are missing from the order set (generally an order that wasn’t reconciled).

Patient Lists

• System lists are available for the floor, stroke, stroke consult and general neuro consult services under Available Lists → Services MSH → Neurology. For easy access, you should create your own list (under My Patient Lists) and click and drag these system lists over into your own. This gives easier access, and lets you customize the data columns that are shown for each list.

• To add a patient to one of the service lists, locate the patient in the “ED Patients” list, or the appropriate unit in the “Units” list. Right-click on the patient name and select “Treatment Team.” For stroke, type “stroke” in the search box and choose the appropriate team; for general neuro, type “neuro” and select the correct team (Neuro Consult or Neurology Floor Service) – unfortunately there are outdated entries here that can be confusing mess, but you should always choose the one that ends in “(aka NEURO)”

• For patients that you have accessed by some other means (i.e. searching by name or MRN), you can add a treatment team by clicking on the “PCP” box in the top banner, which also opens the care teams activity. Alternatively, you can add a patient you are admitting to a list by utilizing the “Add to Inpatient Treatment Team” order in the admission order set.

• Before printing, sort the list in the order that you want (generally by room number or alphabetically) by clicking on the relevant column header. Then press the print list button in the upper right hand corner. You can select which columns to print from the print dialog box.

• Find some way to keep track of discharged patients as they will drop off the service lists as soon as they are discharged and you may not have done the discharge summary yet. You may want to create a separate personal list where you can click and drag over individual patients. They will stay on this list even after falling off the service list.

Sign-Out

Enter signout information should in the To do box of the Handoff tab. You can open the Handoff sidebar by clicking Signout Neurology tab and selecting Handoff. The information in the “To Do List” is lost once it is deleted – this is not where you place crucial information, but rather where you can indicate ruminations, speculations, instructions, etc. that you may wish to pass on to the oncoming resident but do not want to remain part of the permanent medical record.

Epic Text

Key System Smart Phrases

• VITALS – last 24 hr vital signs with ranges

• LABS - List to select standard inpatient labs from last 72 hrs

• EDLAB24– Pulls in ALL labs from last 24 hrs

• LDAS – List location/duration of lines, drains, catheters

• CMED – Current medications (generally inpatient)

• CMEDPLAINOP – Outpatient meds that were reconciled

• ISTOP – document verification of controlled substance scripts in NYS database You can also create your own smart phrases for your own exam, frequent recs, etc.

Key Smart Texts (note templates)

• .Neurocongen – General Neuro Consult Note (see 'Consult Notes' section)

• MS IP MD NEUROLOGY NOTE – General Neuro H&P

• MS IP MD NEUROLOGY PROGRESS NOTE – General Neuro Progress Note

• MS IP MD STROKE SERVICE CONSULT NOTE – Stroke Consult Note

• MS IP MD STROKE SERVICE ADMISSION NOTE – Stroke H&P

• MS IP MD STROKE PROGRESS NOTE – Stroke Progress Note

• MS IP NEUROLOGY DISCHARGE SUMMARY – only if it did not auto populate

• MS IP MD LUMBAR PUNCTURE – LP procedure note

• MS IP MD CRITICAL CARE HOUSE STAFF PROGRESS NOTE – NSICU only

• MS IP MD STROKE SERVICE MSQ TELEPHONE CONSULT (26055) -- for use with telephone consultations with MSQ.

Admission Order Sets

• NEUROLOGY GENERAL ADMISSION MSH IP

• NEUROLOGY STROKE ADMISSION MSH IP

• NEUROLOGY POST TPA STROKE ADMISSION

Inpatient Order Sets

• DIABETIC AGENT MSH IP – sliding scale/basal insulin, glucometer orders

• LUMBAR PUNCTURE POST PROCEDURE MSH IP (better to use downtime form)

Discharge Order Sets

• Neurology Discharge – all discharges; can only be placed from discharge navigator

• DISCHARGE ORDERS FOR DECEASED PATIENTS ONLY – all inpatient deaths

Epic Login Contexts (Departments)

• Choosing the correct context will allow you to access the appropriate activities and signouts for each department/area of the hospital

• NEUROLOGY [41] – Inpatient neurology services at MSH – all of your inpatient work should be done here

• HOSP NEUROLOGY [5101207] – General Neurology Clinic and MS Clinic

• HOSP NEURO HEAD [5101209] – Headache Clinic

• HOSP NEURO MOVE DIS [5123104] – Movement Disorders Clinic

• CRITICAL CARE/ICU [73] – access critical care signouts for NSICU

• PSYCHIATRY [50] – Unhide psych floor bed lists - useful when locating consult patients on these units as they are hidden by default

• EMERGENCY DEPARTMENT [5119226] – has some links to systems not available elsewhere (ie HealthIx)

Miscellaneous Epic Tips

• You can save any order set to your favorites by searching for it, then right clicking and choosing “save to favorites” so that you do not have to search for them each time.

• Ordering labs for lumbar punctures can be unreliable in the computer, as Epic aggressively cancels what it thinks to be duplicate orders. This means that one of your cell counts/diff will almost always be canceled, even if you order them for tubes 1 and 3 in the computer. To avoid this, CSF studies should generally be ordered on a downtime form, or confirmed by calling the lab.

• Epic allows you to make templates for notes, which can save you time when entering your exam, or with clinic notes. To open the template editor, click the “Epic” button in the top left corner → Tools → My SmartPhrases. You can also share your templates with others, so ask for access if you see someone with a template that you like!

Epic/Email Remote Access

On Your Computer:

• Go to First Time VPN Remote Access - register for a VIP security code.

• You may need to download and install Citrix Receiver on your computer Citrix Receiver

• Go to https://msvpn.mountsinai.org - enter your MSH login and password. Then enter VIP security code from the VIP app on your computer or phone.

• Click on the Citrix Applications -> Epic Production. You may need to download a new instance of Epic each time. You can find this in your downloads folder and double-click to open Epic.

This method of access may work on some mobile devices with the Citrix Receiver app and a compatible browser (i.e. Firefox for Android) installed, if instructions below do not work

On Your Mobile Device:

• Haiku or Canto – this is useful for looking up basic patient information/labs and outpatient visits, however it is not possible to place orders or write notes. You can see prior notes.

• Download Epic Haiku (iOS and Android, for phones) or Epic Canto (iPad only) from the appropriate app store

• From a hospital computer, search for “Haiku” or “Canto” from the intranet home page, and follow the directions to set up the app on your device.

Access to email on your phone has recently changed. You may need an individualized email link to set this up. Call the IT Helpdesk if you are having trouble, and of course let your chiefs know if you continue to have issues.