Burns 103: Epic charting in the burn clinic Video Lecture | Introduction to Burn Care: Medical Treatment - Health & Fitness

EPIK charting in the Harborview burn
clinic
We will cover the data elements to input
and review orders and smart sets note
templates and closing and forwarding
your notes
as a courtesy order medications and
referrals prior to completing your note
to facilitate patient discharge from
clinics
after you log on to epic be sure to
select HMC burn clinic
on the schedule there are colored dots
that indicate the status of the clinic
visit green indicates the patient is
ready for resident evaluation click on
the green dot and change it to yellow
enter new visit diagnosis or transfer
them from the problem list by clicking
on the paper icon with a blue arrow
it is important to include location
laterality and degree of burn under
encounter type select initial or
subsequent encounter as appropriate
sequelae is rarely relevant in the burn
clinic visit diagnosis should be in the
problem list but not all items in the
problem list will be included in the
visit diagnosis and relevant
comorbidities as a visit diagnosis
specifically those considered for
operative risks for example diabetes
contributes to the complexity of wound
care due to the risk of infection
other examples include chronic
anticoagulation and smoking once you
have added visit diagnoses click mark as
reviewed
one hundred orders tab there is a smart
set called burn wound care
right-click on it add it as your
favorite and I will show up for every
patient you can order topical meds given
to the patient in clinic and place
referrals for rehab psychology and
occupational therapy
for medications verify the pharmacy and
II prescribe all medications except
narcotics which must be printed for
Labor and Industry patients enter in
medications and pend the orders for the
attending to sign
be assured also mark as reviewed
allergies and past medical history
is this a new or established patient to
help you determine this click on the tab
mindscape then transcripts to see if the
patient has been seen before by a member
of the team look for a discharge summary
in clinic note or a consult note if the
patient was fast tracked burn falls
under the general surgery group and
billing providers are attendings in a
RMP or pas if there is no billing
providers a test station in the last
three years the patient is established
otherwise it is a new patient
burn heals some patients develop a scar
which can be graded for future
comparison go to more activities flow
sheets then click on the tabs and Coover
scar scale enter the numbers to grid
this car the worst site is usually
graded to grade more than ones car click
file to save the column then enter
column press ok when the date and time
box pops up and a new column will appear
this is automatically imported into the
note if it is completed before starting
the note
for progress notes there are three
templates acute burn healed burn and
late effects burn
select the appropriate note template
template press s2 to fill in the field
the template is a skeleton to assure
that burn related items are included in
the note additional elements can be
entered with no writer or free text to
add history from the chart which is
necessary for all preoperative history
and physicals use da phrases dot p.m.
age from past medical history SOC for
social history F a.m. Ajax for family
history select our OS or physical exam
at the top of the note here you can
select symptoms within the review of
systems or physical exam findings within
each system include relevant systems
that you observe and examine when
interacting with the patient such as
those marked here your selections will
then show in the note to graphically
describe physical exam findings click on
one of the other systems such as skin or
musculoskeletal select a specific area
that is injured use the pencil to draw
the area burn healed not yet healed or
donor site select the hashtag and click
on the location to add a description the
image and description will show in the
note
continue to use f2 to complete your note
under assessment plan choose the first
option and the visit diagnosis you
previously entered will be imported type
additional free text to reflect your
full assessment and plan so forward your
note select new communication under the
communications tab
primary care provider and any other
providers is the recipient and route the
draft to P you h-i-m letter pool
complete the letter as needed before
routing upon closing encounter
to close the visit under the discharge
tab select level of service collect
level of service and a box will pop up
to help you to determine the level based
on complexity of history exam and
management
the components that define the level of
complexity are summarized in this chart
be sure to add GC to indicate you are
resident seeing the patient if you see a
telemedicine patient add GT and now
you're ready to close your note and
forward to your attendant