Epic for Mortals

Reference and syllabus for EpicCare Ambulatory

Daniel Rosenberg MD

Leda and the swan.

1510-1515, Giovanni Antonio Bazzi, after Leonardo da Vinci.

“He who wishes to be obeyed must know how to command.”

—Niccolò Machiavelli

Last revised 17 October 2018

© 2017-2018 Daniel Rosenberg MD, Providence Medical Group. May be used by any Epic customer without
charge; please preserve this notice. Do not re-distribute outside your organization given that the
screenshots constitute Epic trade secrets.
 The painting on the frontispiece depicts the myth of Zeus, in the form of a swan, seducing unknowing Leda
and bearing the twins Castor and Pollux (and a third mysterious egg). Sure, Zeus is powerful, difficult to
control and vexatious, with inconsistent manifestations, but he gets the job done.
Introduction

Introduction
Our job is hard. Patient care is challenging, and our schedules busy. We balance the
vigilance of avoiding deadly mistakes with our family lives, and finding the time to pee.
Nevertheless, how many people have you met who think their job is easy? Sure, we
spend 2 hours fiddling with the EMR for every hour we spend in front of patients1, which
is a travesty by any stretch. But it’s no cakewalk for gas jockeys, salespeople, or
restaurateurs either. This guide is designed for clinicians who have been using Epic for at
least a few months and want to make the best use of it. It is not a beginner’s guide.

I can tell you from experience that writing lousy software is moderately challenging, and
writing good software is incredibly hard. Making complexity seem simple is as difficult as
spending enough time with your patients and going home with your notes done. If you
think using Epic is difficult, ask yourself how expert you really are at using your word
processor or spreadsheet. Then remember that Epic is all of those and a thousand other
things crammed together in one place, with a bunch of traffic cops so we can all work on
the same patients together. These tools are not purposefully abstruse. Hard-working,
smart people work on them tirelessly. In my experience, many of the greatest software
engineers2 are significantly more bananas than the most skilled clinicians, with a singular
drive to do things better. I know it doesn’t often seem that way, and indeed our tools
could and should be more intuitive.

One day, Epic will be easier to use. In the meantime, the goal of this work is to make
somewhat experienced users of the Epic Ambulatory EMR more confident that they are
wringing every reasonable efficiency out of it. We are fortunate to work in a respected
calling that still makes sense. We owe it to ourselves and the patients we care for to
resist shoddy notes, cynicism, and self-pity. I aim to help you take back control.

This guide is long, but since you’re already using Epic, everything in here is gravy, and
you don’t need to devour the whole thing at once. It’s divided into 3 sections: a Strategy
guide outlining competing strategies of how to get through your day; a Reference guide
about completing specific tasks; and an Appendix of lists and minutiae I hope you will
find useful.

N.B.: This document is filled with hyperlinks to various places inside itself. To get back to
where you were after clicking on one, type Alt- (alt key + left arrow key held down
together, option- on a Mac, option-[ in Mac Preview3). Control-F (command-F on a
Mac) will search for you too. Use the PDF Bookmarks to navigate (ribbon icon).

1
Ann Intern Med. Published online 6 September 2016 doi:10.7326/M16-1757
2
References provided upon request
3
Google Chrome PDF viewer does not have a “navigate back from link” command as of
December 2016.
Contents

http://xkcd.com/1343/

Contents
 Control-F to search (command-F on a Mac), click on a section to jump to it.

............................................................................................................................................ 1
Introduction ........................................................................................................................ 2
Contents .............................................................................................................................. 3
Strategy guide ..................................................................................................................... 8
Dock your progress note to the sidebar ......................................................................... 8

Get a bigger monitor................................................................................................... 9

Use a good Preference list ............................................................................................ 10

Use keyboard shortcuts ................................................................................................ 11

Prepare your charts beforehand .................................................................................. 14

Chart in the exam room ................................................................................................ 17

Make your A&P your AVS ............................................................................................. 18

Maintain the Problem list ............................................................................................. 19

Progress notes: elements of style ................................................................................. 20

Be parsimonious ....................................................................................................... 20

Format for clarity ...................................................................................................... 21

Spelling auto-correction ........................................................................................... 23

Use a lot of SmartPhrases ......................................................................................... 25

Dotless SmartPhrases ............................................................................................... 25

Consider a scribe ....................................................................................................... 26

Progress notes: mechanics of your charting strategy................................................... 26

Orthodox problem-oriented charting ....................................................................... 26

Reformed Problem-oriented charting with .DIAG .................................................... 30

3
 Use NoteWriter (or parts thereof) ............................................................................ 32

Use Send Message QuickActions .................................................................................. 39

Contents Graphics in your AVS..................................................................................................... 44

Use Chart Search........................................................................................................... 44

Schedule your own appointments ................................................................................ 45

Cancel appointments ................................................................................................ 47

Customize schedule columns .................................................................................... 49

Customize your toolbars and workspace...................................................................... 51

Customize the main toolbar ..................................................................................... 51

Choose the startup activity ....................................................................................... 52

Customize the patient workspace ............................................................................ 53

Consider the Widescreen view ..................................................................................... 55

Reference guide ................................................................................................................ 57

Care Everywhere ........................................................................................................... 57

First steps: Request Outside Records ....................................................................... 57

Care Everywhere activity .......................................................................................... 60

Care Everywhere records in Chart review ................................................................ 62

Viewing reconciled information................................................................................ 64

Reconcile Outside Information activity .................................................................... 64

Scheduling ..................................................................................................................... 66

Scheduling your own appointments ......................................................................... 66

Appointment Desk and Visit type flags ..................................................................... 66

Patient FYI flags............................................................................................................. 71

Care teams .................................................................................................................... 72

Letters (a.k.a, the Communications and Letters activities) .......................................... 74

Communications activity .......................................................................................... 74

Letters activity .......................................................................................................... 79

Communication Management navigator section ..................................................... 80

SmartTools .................................................................................................................... 81

SmartPhrases ............................................................................................................ 82

4
 SmartLists.................................................................................................................. 90

SmartLinks................................................................................................................. 96
Contents In basket...................................................................................................................... 108

Organizing the In basket ......................................................................................... 108

Dealing with results ................................................................................................ 111

Postponing messages.............................................................................................. 118

In basket QuickActions............................................................................................ 118

Attach in baskets..................................................................................................... 122

Out of office assistant ............................................................................................. 124

Sent Messages In basket ......................................................................................... 127

Completed Work ..................................................................................................... 127

In basket message search ....................................................................................... 127

Secure patient messages ........................................................................................ 128

Chart Review ............................................................................................................... 132

Joining existing encounters..................................................................................... 133

Routing notes and labs from Chart Review ............................................................ 134

Chart Review filters ................................................................................................. 135

Media tab ................................................................................................................ 136

Order review ............................................................................................................... 137

Visit navigator ............................................................................................................. 138

Visit navigator speed buttons ................................................................................. 138

Order entry ............................................................................................................. 141

Meds & Orders ........................................................................................................ 143

Visit taskbar ............................................................................................................ 148

Medication review .................................................................................................. 149

Charge capture........................................................................................................ 151

Patient lists ................................................................................................................. 154

Patient lists activity overview ................................................................................. 154

Building your own list ............................................................................................. 157

Sharing patient lists ................................................................................................ 158

5
 Setting a default list ................................................................................................ 159

Adding and removing patients from a list on the fly .............................................. 159
Contents Orders preference lists ............................................................................................... 160

Preference list composer ........................................................................................ 162

Health maintenance ................................................................................................... 173

MyChart ...................................................................................................................... 175

Result release .......................................................................................................... 175

Reviewing sent messages ....................................................................................... 176

MyChart proxies...................................................................................................... 179

Episodes of care .......................................................................................................... 182

Anticoagulation navigator .......................................................................................... 183

Viewing the anticoagulation episode ..................................................................... 188

Infusion navigator ....................................................................................................... 189

Reporting .................................................................................................................... 194

My Reports tab ....................................................................................................... 194

Report library tab .................................................................................................... 195

Creating or editing a report .................................................................................... 197

Appendices ..................................................................................................................... 218

Useful SmartLinks ....................................................................................................... 218

Useful SmartPhrases ................................................................................................... 225

Differential diagnoses ............................................................................................. 225

Miscellany (Tips & Tricks) ........................................................................................... 225

Edit multiple orders ................................................................................................ 225

Place an order as another user ............................................................................... 227

Keeping track of families......................................................................................... 229

More keyboard shortcuts ....................................................................................... 230

Finding your own patients ...................................................................................... 230

6
Contents

http://xkcd.com/731/

Cape Kiawanda, Oregon coast

7
Strategy
Strategy guide
guide
There is more than one way to skin a cat.4 The following present solutions that various
Dock your progress clinicians have used successfully, but your success with any one of them will depend on
note to the sidebar your predilections and personality traits.

Dock your progress note to the sidebar

With your note in the sidebar, you can use Chart Review (and other activities) to gather
information while typing your note, instead of switching back and forth. There’s a button on the
upper right of the Progress note section which will move the note over:

Button to dock the note to the sidebar (Epic 2014)

Pop art version of sidebar button, Epic 2017

Arrow button when you don’t have a choice of floating window

With the note docked to the sidebar, there’s less scrolling needed to move between navigator
sections (like Meds & Orders and Problem list) and your note. I know that doesn’t sound like
much, but sheesh it has saved me a lot of grief. As of Epic 2018, this button tends to disappear
and you may not be given any option other than writing your note in the sidebar.

4
Smith S. The money diggers. 1840. N.B: It turns out there’s only one good way (when it’s dead).
8
Strategy
guide

Dock your progress

note to the sidebar

With your progress notes

docked to the Sidebar, you
can work on your note and
use Chart review, Meds &
Orders, and other activities
Note docked to Sidebar (Epic 2014)
simultaneously.

Note docked to the sidebar, Epic 2017 widescreen view

Get a bigger monitor

Docking your note to the sidebar works better on 22 inch or larger monitors. On a smaller (e.g.,
20 inch) monitor, Epic will sometimes complain about being squished and the sidebar note will
pop out into its own floating window (where it won’t fit anyway). You can still dock your note to
the sidebar on a 20 inch (1600 x 900) monitor, just like you can fly to Australia in coach
squeezed between two linebackers, but it doesn’t mean you should put up with it if you have

9
 other options.5
Strategy
Use a good Preference list
guide
If you develop a strategy for not suffering when you order labs, imaging, immunizations
and referrals, your cortisol numbers should go down and your patient satisfaction up.
Use a good
Preference list But, building and maintaining a well-organized preference list isn’t for everybody. I think
your primary strategy if possible, should be: Find someone else in your department who
already does this and copy theirs. (The details of how to do so are below, in the
Preference List Composer section.) If there isn’t one already, your medical director can
appoint a Chief Nerd and have them work with a CIS or provider informaticist to adopt
another set of orders preferences for your clinic. That way you can have commonly-used
orders with easy to remember, descriptive names that work the way you expect.

Strategy 2: every time you write an order you are going to use later, and before you sign
it (from either Meds & Orders or Order Entry), you can click the star next to it:

That will add it to your generic “Orders” preference list by default, but you can use the
box in the upper right to add it to another preference list, and/or section on that
preference list:

5
You have other options. 3 new 22-24 inch monitors ($240, $377 respectively at press time
compared to $146 for an obsolete 20 inch monitor) cost less than the difference between your
typical coach and business class ticket. The 1600 x 900 resolution on most 20 inch monitors is
below Epic’s recommended 24 inch 1680 x 1050 minimum; Epic says you’ll save 1500 clicks per
day with a bigger monitor. I’d suggest 1920 x 1080 / 22 inch since the program is likely to only get
greedier. Spec out your exam rooms first: 24 inch monitors can seem big enough to make it hard
to see your patient.
10
Strategy
guide

Use keyboard
shortcuts

Leave as few blanks as possible, and give the preference list entry a good display name,
one that is both descriptive (as above, metformin 500 mg tab 1 daily #30) and looks
distinct enough from other entries you can tell at ordering time that it’s a friendly
member of your preference list.

Strategy 3 is the most labor intensive but more likely to leave you with a usable list
rather than a disorganized pile. Use the Preference List Composer to build a well-
organized set of lists. That’s involved enough to have a section of its own—follow the
preceding link to see it. Making your own lists requires that a detail-oriented person fill
in as many boxes as possible for every common order your group typically comes across.
(If you leave boxes blank, they remain blank at order time and then you have to fill them
in every single time you use the preference list entry.)

http://xkcd.com/1339/

Use keyboard shortcuts

Some things, like highlighting text, are best done with mouse. Others are more quickly
accomplished with a keyboard, especially common commands with small target areas

11
 that have a habit of floating around to unpredictable parts of your screen.6 By
Strategy remembering a few keyboard shortcuts, you may save yourself significant time and
frustration. It also helps when you’re documenting in a patient room: you can keep your
guide eyes on the person in front of you, rather than looking for the current position of
various buttons on the screen. (Keyboard shortcuts can be done with muscle memory;
Use keyboard the mouse won’t work that way unless you have ESP.)
shortcuts
You don’t need to memorize all of the commands below, but the ones starting with
Control-shift are especially useful. Epic 2014 uses a blue question mark icon at the
bottom of the visit navigator, which contains a keyboard shortcut pop-up:

In Epic 2017 and widescreen navigators you might look in the “ellipsis” (…) menu on the
upper right to find the keyboard shortcuts help popup:

Shortcut Destination or action

Control-shift-A Allergies
Control-shift-B BestPractice alert section
Control-shift-C Chief complaint
Control-shift-E End (sign) encounter
Control-shift-F Follow-up section
Control-shift-G Visit diagnoses
Control-shift-H History
Control-shift-I Patient instructions
Control-shift-L Level of service
Control-shift-M/N Progress note/NoteWriter
Control-shift-O Meds & Orders
Control-O Start an order in the Visit taskbar (Order Entry
activity prior to Epic 2018)
Control-shift-P Problem list

6
Viz. Fitt’s Law (user difficulty is a function of distance to the target and width of a target) and
Hick’s law (the time it takes for a person to make a decision is a logarithmic function of the
number of choices). Taken together these two explain a lot of why EMR’s drive people bonkers.
12
 Control-shift-S SmartSets
Strategy Control-shift-V Vital signs
Control-R Chart Review
guide Control-S Sign and close the encounter (Epic 2018+)
Control-Z Undo the last thing you typed
Use keyboard Control-Y Redo the last thing you undid
shortcuts Control-spacebar Chart search
Alt-g Sign a pending order
Alt-s Sign an open SmartSet
Sign an order in Epic 2018
Alt-shift- (left arrow) Open visit sidebar (prior to Epic 2018)
Alt-shift-→ (right arrow) Close visit sidebar (prior to Epic 2018)
Esc (escape key) Close a pop-up window or list
Control-space-home Move between sections and activities (Epic 2017)
Keyboard shortcuts for moving around the Visit navigator

In addition to shortcuts you can use to move around the Visit navigator, there are
shortcuts when entering text:

Shortcut Action
= Enter the same thing in this box that I
put in last time (for example, in Patient
station, re-enter the last patient I put in
here)
F1 Context-sensitive help (gives you help
about the activity you’re in, even if
there’s no help button—can be
surprisingly helpful!)
F4 Insert a row in a table (such as Past
medical history or Family history)
F2 Move to the next wildcard (***) or
SmartList
Shift-F2 Moved to the previous wildcard or
SmartList
Shift-F4 Delete a row in a table
Shift-F5 Equivalent to clicking on the magnifying
glass of a selection box
Control-F11 Refresh SmartLinks (for example, you
updated a problem-based Assessment &
Plan or PHQ-9 flowsheet entry and want
to see it in your note)
T In date entry fields, puts in today’s date.
T+3 In date entry fields, means today’s date
plus 3 days. You can also subtract days,
like T-10 to mean 10 days ago.

13
 W+5 As above, but 5 weeks from now.
Strategy M+6 As above, but 6 months from now.
Y+2 As above, but 2 years from now.
guide N In time entry fields, put in the current
time (T works here too).
Prepare your charts N+3 When entering time fields, puts in the
beforehand current time plus 3 minutes
H+2 As above, but adds 2 hours.

Prepare your charts beforehand

If you have an amazing memory and can remember all of the recent interventions, lab results,
and consultations on your loquacious, elderly, diabetic, hypertensive bridge player with multi-
organ disease, you may skip this section. Or, you can feel free to look over their chart while
they’re sitting in your exam room, as some of the remaining precious seconds of their life tick
by. Remember not to miss any life-threatening details!

Otherwise, consider having a system of preparing charts before the visit.7 Time you spend here
you can make up with shorter (and better) office visits, and less time tossing and turning at
night, reviling yourself for forgetting to renally dose their metformin.

You have the following options (the first one is the best, I think):

• Open up the appointment (days or weeks) before the patient arrives and start
documenting your HPI. In Epic 2017 and later, you can open up the visit well
before the patient arrives. You’ll use the Pre-Charting workspace, a widescreen
view subset of a regular visit encounter. You can start a skeleton note for the
visit, pend (or order) labs, and review BestPractice Alerts. Any chart notes you
enter will hang around, otherwise invisible except inside the encounter, until
the day your patient arrives. Note: if the appointment gets cancelled and
rescheduled, you’ll need to go into the cancelled encounter and copy the note
out and into the new one. After some amount of time any old notes from un-
arrived encounters disappear. (That amount of time is 90 days at Providence;
Epic’s default is 30 but that means the notes of your flaky, complicated no-
shows may vaporize before they can reschedule.) If you sign orders while pre-
charting, you’ll need to cancel them if, say, the patient gets admitted or moves
to Peru and you don’t want extraneous orders hanging around.

7
Cf. Fam Pract Management. 2015 Nov–Dec; 22(6): 30-38.
14
Strategy
guide

Prepare your charts

beforehand

Pre-Charting workspace

 In case you don’t remember the limitations of the Pre-charting workspace, they’re
spelled out here for you. Chart notes and unsigned orders vaporize 30-90 (vide supra)
days after no-shows or cancelled appointments!

 Click here to start skeletonizing a progress note. Dock it in the sidebar to use Chart
review at the same time.

 Other pre-charting activities are indexed here: manipulate the problem list, visit
diagnoses (if you’re ordering something you’ll need to start entering linked diagnoses),
and Meds & Orders. You also have access (in the left-sided Activities tab) to Chart
Review and History, as well as the More (Activities) menu. Note that you can get
BestPractice Alerts too, which may, in turn, get you into a SmartSet. But some SmartSet
activities may convert the pre-charting workspace to a full-blown encounter.

 Press the “Start the visit” button to get access to the whole visit navigator. Be
prepared to face the consequences, though: you may end up converting the
appointment into an encounter (meaning if the patient doesn’t show up you’ll need to
mark the encounter as an error, usually using the Erroneous Encounter SmartSet) and
any chargeable orders will need to be cancelled. “Start the visit” doesn’t convert the

15
 encounter itself, but a variety of actions you might do in the Visit navigator that results
Strategy will do so.8

guide • Open up the visit encounter just before you go into the patient’s room, and
start the HPI based on the last visit and intervening labs, with the note docked
at the same time.
Prepare your charts
beforehand
• Make a separate documentation encounter. You might create this just after
closing the visit, while it’s still fresh in your mind. Today’s Assessment and Plan
becomes the template for the next visit’s HPI. Use a docked progress note in the
Primary Care chart prep encounter, perhaps with a .prep SmartPhrase like the one to the left,
Chart Prep to skeletonize the next encounter’s HPI while reviewing the previous encounter.
This is especially helpful when there’s a lot of information to synthesize. You can
Immunizations append the chart prep encounter if new consults or results come in during the
@IMM@
interim. When the patient arrives, you can use the Copy previous progress note
Health maintenance due button to bring in the text of the Chart prep encounter.
@HMLIST@

Example .prep SmartPhrase if

you’re using a separate
Documentation encounter

Copy previous progress note button (Epic 2014)

Copy previous progress note button (Epic 2017)

Note that if you make a Documentation encounter the same day as the visit,
you’ll need to click the on the “Remove encounter filters” button to see it from
the Copy Previous Note pop-up window:

8
You’ll convert an appointment into an encounter by documenting vital signs (or updating
anything else in the Documentation flowsheets), documenting a Chief complaint, using
Annotated Images, documenting in the Follow-up navigator section, Level of Service, MAR,
Patient instructions, MAR, or Questionnaires. See the Encounter Types and Specialist Setup and
Support Guide.
16
Strategy
guide

Chart in the exam

room

Copy previous progress note dialog box

Usually, you’ll use the most recent Documentation encounter (you’ll see your
Chart Prep header on top; that’s why we make it big). Select the text in the
bottom pane you want to include, and click the “Add Text Only” button.

• Use the Pasteboard, which is like the usual copy/paste clipboard, except it has
10 slots (instead of one) and persists if you log out and back in again. Highlight
the A&P, and press Control-E to stick that on the Pasteboard (or use the right-
click context menu Copy to Pasteboard option). The next time you see the
patient, get in the progress note and press Control-E again to bring up the
Pasteboard with your last note (and/or consult) right in front of you.

Chart in the exam room

Spending your time in the exam room interacting with the computer instead of your
patient is a sad manifestation of contemporary alienation. But charting in the room
doesn’t have to evoke Franz Kafka. You can get two birds with one stone by sharing the
screen with your patient, getting a little bit better with your typing (or using a scribe),
and charting while you talk. You can type the HPI as the patient weaves their tale, and
review your Assessment and Plan as you type it: “So, we’re going to increase your
mealtime insulin from 3 to 5 units, and keep your Lantus at 18 at bedtime.” (Imagine
tickling the plastic keys with the phrase in italics.) You get to review the plan out loud,
checking for errors and understanding along the way. This takes getting used to, but one
gets better with practice.

17
 Make your A&P your AVS
Strategy Many clinicians are in the habit of writing lucid instructions for the patient, and then a
more detailed, jargon-filled assessment and plan later, when they should be home
guide watching “Wheel of Fortune” with their families. There’s no rule that says you can’t use
your Assessment and Plan for your patient instructions. Make your A&P lucid enough for
Make your A&P your your patient while you detail your medical decision-making. Your patients won’t mind
AVS you writing a bit about your differential diagnosis, and if you need to include fancy
words, they have dictionaries. (Or if you’re an overachiever you can explain in
parentheses. Or, where appropriate, just leave out the fanciness since we’re not really
impressing anyone anyway.) Our coders and the government will like this just fine, even
with the second person indicative:

Diabetes mellitus type 2 with nephropathy

Control not quite adequate on current regimen with A1c of 7.8 last week.

We reviewed the risk of worsening kidney disease with blood sugars that
were too high.

Increase your mealtime insulin (Novolog) from 3 to 5 units, and keep your
Lantus at 18 units at bedtime. We’ll recheck your hemoglobin A1c at your
next visit in 3 months.

You can copy and paste your plan from the Patient instructions section to your progress
note and flesh it out a bit later (or use the .PATINSTR SmartLink). Or, if you’re using
Problem-oriented charting, use a SmartPhrase to pull your assessment and plans into
the progress note and AVS.9 You can even do this bilingually, so long as everything
needed for billing is in English (pardon my Spanish):

Assessment/Plan
Diabetes type 2, uncontrolled
Successfully increased insulin NPH from 25 to 30 units twice daily. Given
CBG's, will increase again, from 30 to 35 units.

Will check A1c again today, along with microalbumin. Referred to

optometry for eye exam.
Refilled lovastatin.
Flu vaccine today.

- Sube otra vez a la dosis de insulina, 1 unidad dos veces al día cada
semana, hasta 35 unidades dos veces al día
- Si los temblores no se mejora dígame; llamene aquí si hay niveles de
azúcar menos que 90.
- Hace una cita con oculista para chequeo de los ojos en diabetes

9
I’m too lazy to type .probapnotes, so I made .ap a shortcut SmartPhrase (with the contents
“@probapnotes@”) instead. See keyboard shortcuts below to learn about why, for my AVS, I just
type Control-shift-I .ap, and I’m done.
18
 Maintain the Problem list
Strategy Your effort to keep your Problem list up to date is worth it. If your mom had a
complicated history and she was seeing many specialists, you’d want her to have a well-
guide curated, updated problem list. Who is responsible for doing this? Whatever clinician is
looking at the chart, including the PCP in the outpatient clinic, specialists using Epic, and
Maintain the Problem the inpatient team.
list
• Resolve old problems that no longer directly affect medical care; inactive ones
that are important keep in mind about can go on Past medical history (like
resolved cancer; right-click to see options about moving a problem to its
retirement home, or back again);
• Unresolve a recurring problem instead of creating a new one, which preserves
the old Overview and any associated Assessment & Plan notes (click the Show
Past Problems box at the top of the Problem list, locate your resolved problem,
right click on it and select Make active);
• Delete problems that shouldn’t have been there in the first place (such as
duplicates; right click, then select Delete);
• Use an Overview for complicated problems to share with other clinicians your
hard-won insights;
• Consider prioritizing problems (as high, medium, low) to lend an organizing
principle to a lengthy problem list;
• Change problems as you refine your diagnosis; go into the Details to change
Ankle pain to Gout once you’re reasonably sure that’s what it is. This prevents
extra entries on the Problem list to sort through, and preserves all of your
Problem-oriented Assessment & Plan notes under one place.

Changing a Problem list entry looks like this:

1. Click on (for example) the Chest pain diagnosis to get at all the options of the
problem…

2. Click on the Details link (highlighted yet) to get at the diagnosis code stored in
this Problem list entry.

19
Strategy
guide

Progress notes:
elements of style

3. Type a more refined diagnosis in the Problem field (highlighted yellow; the
Display field reflects only what you want to call the problem, not its underlying
diagnosis code).

4. Select an appropriate new Problem diagnosis that will supersede the old Chest
pain diagnosis.

Progress notes: elements of style

Our interactions with patients are evanescent; progress notes are forever, and the sum
of these will end up being most of your legacy when you’re gone. In my view, all of
Epic’s legion other buttons and menus are mere handmaidens to writing a lucid progress
note.

Be parsimonious
Just because you have access to a lot of SmartLinks to bring in a complete medication
list, family history, and past surgeries doesn’t mean using them your progress note
about an uncomplicated sinus infection is any more glorious. You can’t bill for the extra
verbiage if it’s not medically necessary, and it makes the note harder to read. Phrases
like “A broad differential diagnosis was considered, covering a variety of potential
causes of the presenting systems, and reviewing all recent laboratory data and past
history” are not likely to protect you in a court of law, as they are simply non-specific

20
 sacrifices to the gods of adjectives and spirits of passive sentence construction, and
Strategy don’t truly document your thinking process if you’re not specific.

guide Also, short sentences are easier to read than long ones.

Format for clarity

Progress notes: You tell me: what’s easier to read?10 This:
elements of style
Subjective
• Preventive. Flu vaccine done 9/2016. AWV due 2/2017. Td due 1/2017.
• Dyspnea, suspected due to exacerbation of emphysema. PFT's (following
up from 2014) similar. Echo showed new LV enlargement with reduced R
systolic function. Noted no leg swelling or orthopnea but slight cough, some
chills. Seems better now. Was walking 1.5-2 mi/d. Now walking 3/4 mi/d.
Says it's not dyspnea, but his body hurts.
• DM2. A1c 7.1 7/2016, down from 7.4. Planned repeat 1/2017. CBG's AM
112-130, PM 99-155.
• Carotid disease s/p CEA. Carotid u/s stable 8/2016, planned 1 y repeat
with AAA u/s.
• AAA. AAA u/s was non-diagnostic 8/2016. Given 3.1 cm finding, consider
q3y ultrasound.

Or this?

SUBJECTIVE
Preventive. Flu vaccine done 9/2016. AWV due 2/2017. Td due 1/2017.
Dyspnea, suspected due to exacerbation of emphysema. PFT's (following up
from 2014) similar. Echo showed new LV enlargement with reduced R systolic
function. Noted no leg swelling or orthopnea but slight cough, some chills. Seems
better now. Was walking 1.5-2 mi/d. Now walking 3/4 mi/d. Says it's not dyspnea,
but his body hurts.
DM2. A1c 7.1 7/2016, down from 7.4. Planned repeat 1/2017. CBG's AM 112-
130, PM 99-155.
Carotid disease s/p CEA. Carotid u/s stable 8/2016, planned 1 y repeat with AAA
u/s.
AAA. AAA u/s was non-diagnostic 8/2016. Given 3.1 cm finding, consider q3y
ultrasound.

Most of the controls you’re used to in a basic word processor are present in Epic, like
boldface and bullet points. (So are fancier ones, like tables and colors, but that’s best for
templates, and not notes you type out.)

In Epic 2017, you can personalize what formatting tools appear in the progress note
toolbar from under the “star” menu:11

10
OK, I know you aren’t in this to win design awards for your progress notes. But once you
develop a few good habits, it doesn’t really take any more time, and I claim that well-formatted
progress notes add enough clarity to improve patient care and safety.
11
This is still a “star” menu in Epic 2017, even though you don’t actually star your favorite
formatting tools anymore as one did in prior versions.
21
Strategy
guide

Progress notes:
elements of style

(In Epic 2014 or earlier, you just mark your favorites with stars.) You don’t have to use
everything I do, but I find the following helpful:

You can store fancy formatting in your note templates SmartPhrases (like .SOAP; that’s
what I do with bullet lists, bold headings, and indentation). That way, you don’t have to
mess with fancy formatting much, since your note template already includes the
fanciness. You can avoid clutter by removing items from the progress note toolbar you
never use, such as Insert dictation or anything that has a simple keyboard shortcut (like
Control-b for bold).

I recommend minimalism12 in formatting. I stick to the Arial font, 11 point type size most
of the time (it’s what Epic chose as a standard, matches SmartTool output as of Epic

12
“Good typography can help your reader devote less attention to the mechanics of reading and
more attention to your message.” Viz. Butterick’s Practical Typography for a practical and
philosophical guide.
22
 2014 and is guaranteed to work on any printer). For emphasis (usually just in headings) I
Strategy use boldface, as it’s more noticeable and not as funny looking as italics in Arial. And I
use bullet points as illustrated in the Subjective section above. For my physical exams, I
guide use hanging indents (see below; others use tables). That’s it: no multiple colors or fonts,
which can be distracting and may not lend clarity.
Progress notes:
Spelling auto-correction
elements of style
I’m a lousy typist. For example, I tend to capitalize the first two letters of a word instead
of just one:

I don’t just correct the misspelling, I set it to AutoCorrect:

23
Strategy
guide

Progress notes:
elements of style

A sentence should
contain no
unnecessary words,
a paragraph no Whenever I make the same typo in the future, Epic will apply the correction for me.

unnecessary Details of spelling correction

So long as you’re going to use auto-correction, it’s worth knowing the details of your
sentences, for the personal dictionaries and how to repair things when they go wrong. Head over to Epic
same reason that a menu > Tools > Spell checker > User dictionaries. The first tab shows words we want the
spell checker to ignore (e.g., Epic, stop telling me I don’t know how to spell “Abilify,”
drawing should have
because that’s a real thing):
no unnecessary lines
and a machine no
unnecessary parts.

—Wm Strunk, Jr. The

elements of style.

You can use the “Add to dictionary” item in the context menu illustrated above to add
ostensibly misspelled words to this list. (That is, words like “Abilify” that really are
words, at least according to some people, but aren’t recognized as such by Epic’s spell
checker.)

24
 The second tab, Misspelled words, is where you can add words that you want to always
Strategy fail spell-checking. I don’t find this is commonly used; Auto-correct (as below) may be
more convenient.
guide
The third tab is the Auto Correct list: anything you type in the first column gets changed
to the equivalent in the second column, as shown above. I find this is a great way to
Progress notes:
automatically correct common typos, similar to the way many word processing
elements of style
programs (and text messaging apps) work.

Some people will use this to make “Dotless SmartPhrases,” as noted below. Proceed
with care.

If you mis-auto-correct a word (for example, you told Epic to replace “Wherever” with
“Whenever”) you would fix that here in the third tab. Find your incorrect correction in
the alphabetized list here, highlight it, put the correct re-spelling in the second box on
the right, then click the “Add/Update Word” button. Don’t miss that button part,
otherwise Epic will ignore your re-correction.

Use a lot of SmartPhrases

I have SmartPhrases for patient instructions for common conditions, physical exams,
consultant referrals, and test results. And, I use a library of SmartLinks to return recent
previous weights, blood pressures, labs, portions of the medication list (like
“.medspsych”), and upcoming appointments. Many of are laid out in the SmartPhrase
section of the Reference guide, below.

Dotless SmartPhrases
If you’re feeling extra brave, you can use the same Epic menu > Tools > Spell checker >
User dictionaries activity, on the third (Auto-correct) tab to add a word (using the
25
 Add/Update Word button) and an expansion, like changing all instances of “qd” to
Strategy “once daily.” This is a two-edged sword, however; if you’re free-texting a sig it’ll take
some creative mouse pointing to put in “qd” when you need it to get the patient
guide instructions under the 140 character limit (which is slated to get expanded around
2020).
Progress notes:
Consider a scribe
mechanics of your
If all the foregoing seems like too much, hire someone to do it for you. As of this writing,
charting strategy
our medical group plans to partially underwrite the cost of off-site scribes for interested
PCP’s.13 Given that at least one study shows that for every hour clinicians spend with
patients, they spend two fiddling with the EMR,14 maybe you should subcontract the
fiddling to a willing pre-med who can focus on the typing while you focus on the patient.
Perhaps you’ll get to spend more meaningful time with your patients, or your family.

Progress notes: mechanics of your charting strategy

If you’re reading this, you probably have some sort of strategy you’re using for your
progress notes. You may be wondering if it could be any better. There’s no one method
that’s perfect for everyone or every circumstance, but I’d like to present several favorite
strategies that experienced users advocate.

Orthodox problem-oriented charting

Each problem on your problem list has a slot where you can stick a problem-based
Assessment and Plan note:

You get at the Assessment & Plan note by clicking the Create Notes link (or Edit notes if
there are pre-existing notes), as shown above. You can view previous Assessment & Plan
notes for a given problem by clicking on the Last Assessment & Plan note link just below
the text entry box, or the View All Notes link on the lower right, as shown below.

13
See “Five lessons for working with a scribe,” Fam Pract Manag. 2016 Jul–Aug; 23(4): 23–27.
14
Ann Intern Med. Published online 6 September 2016 doi:10.7326/M16-0961

26
Strategy
guide

Progress notes:
mechanics of your
charting strategy

Remember, Overview notes are designed as signposts for the clinician and don’t
typically end up in the progress note. The Assessment & Plan note ends up in your
progress note, by using the @PROBAPNOTES@ SmartLink. Instead of typing that
yourself, though, you’re better off using a SOAP or APSO note template that includes
@PROBAPNBOTES@ in it. This is my SOAP note template:

@CC@

Subjective

ROS

@HMLIST@

@ALLERGY@

Objective
@VS@

Assessment/Plan
@PROBAPNOTES@

Advantages of “orthodox” Problem-oriented charting:

• When you document by problem, your visit diagnoses get added to the
encounter without extra work;
27
 • Problem-oriented charting is especially useful for Medicare Annual Wellness
Strategy Visits. It makes it easier (relatively speaking) to go through your HCC problems
and document on them15;
guide • You can use the “Copy previous assessment and plan note” button ( ) for a
given problem to use as a template for the current A&P. Or, you can use the link
Progress notes: that says “Last Assessment & Plan note” (right below the Assessment & Plan
mechanics of your box, as above);
charting strategy • Since you’re already in the Problem list, you can put in Patient Goals for Epic to
track (like “BP < 140/90”), see associated medications and lab results, and use
the including Order box (highlighted in yellow below) to automatically link
orders to the problem diagnosis, and see linked medications:

• Problem-oriented charting appeals to control freaks like me, who, given a box,
like to fill it in.16

Note that in Epic 2017’s Widescreen view, you need to use the “Advanced” view of the
Problem list to get the order box and Edit Notes link. If you don’t see these, look on the
bottom for the Advanced View link:

• Most compelling, all of your prior interventions end up associated with the
problem, and you can click the “View all notes” entry (highlighted in yellow,
lower right corner above) to get a catalog over time:

15
Viz. Fam Pract Manag. 2016 Sep-Oct; 23(5):24-27.
16
Like our cat.
28
Strategy
guide

Progress notes:
mechanics of your
charting strategy

You don’t even have to be in an office visit; if you view the Problem list in a
patient chart you’ll be able to see your previous assessments and plans at any
time.

There are significant disadvantages to Problem-oriented charting as well:

• It’s a pain in the neck. The interface needs work (as of Epic 2018). Epic is aware
of this and has promised a fix. In the meantime, every time you want to change
an Assessment & Plan, even for a typo, you will need to schlep to the Problem
list (use the Control-shift-P shortcut), find the Problem, and click into the
Assessment & Plan note, make your correction, head back to your progress note
(Control-shift-N) then refresh your progress note (Control-F11).
• Many people find Chart Search works almost as well for them to find previous
interventions on a problem.
• Not everything you chart on should be in the Problem list. As a rule, I include
anything I’ll have to deal with during more than one visit. Otherwise, I just free-
text my upper respiratory infections at the end of my usual note template.
• There’s no out-of-the-box way (as of Epic 2018) to get your A&P notes listed
with their associated orders. You have to use @PROBAPNOTES@ and then
@DIAG@ separately, which is messy. There is a @PROBDIAG@ SmartLink which
will interleave A&P notes with orders, but (as of Epic 2017) the output is, shall
we say, unsightly:

@PROBAPNOTES@ with no interleaved orders

29
Strategy
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Progress notes:
mechanics of your
charting strategy

@PROBDIAG@ interleaves orders but needs a trip to beauty school

• In Providence Epic, we have made versions of the @ASSESSPLAN@ SmartPhrase

that include Assessment & Plan notes. (Oddly, as delivered by Epic, those aren’t
included.) If you are elsewhere, ask your project team to build them. We called
ours the following:
o PROBAPNOTESWITHORDERS
o PROBAPNOTESWITHORDERSANDOVERVIEW
o PROBAPNOTESWITHORDERSNUMBERED
o PROBAPNOTESWITHORDERSANDOVERVIEWNUMBERED

Reformed Problem-oriented charting with .DIAG

Some people like the organization provided by the Problem list but find clicking into and
out of Assessment and Plan notes too dreadful. They use the “Add problem to visit
diagnosis” icon on the Problem list:

Epic 2014 Add problem to visit diagnoses button

Epic 2017 Add problem to visit diagnoses button

30
 Then, when they are ready to do an Assessment & Plan, they can use the “.diag”
Strategy SmartLink or one of its variants, and then type the Assessment and Plan for each
problem in the accompanying table:
guide

Progress notes:
mechanics of your
charting strategy

For the usual “.diag” SmartLink you’ll need to right click and select “Make selected text
editable” to put anything in the Plan side of the table. You can also use “.diagmed”
which isn’t refreshable, so it doesn’t require that extra step.

Either way, if you add more visit diagnoses after using the SmartLink, you may have to
backtrack with copying and pasting (unless you free-text in the additional diagnoses).
Some people will just let their orders speak for themselves without further A&P
documenting, which can make sparse reading. (Disclosure: that’s me trying to politely
say this can lead to substandard charting.)

Another option is to use the diagnosis comments in the Visit diagnosis section of the
visit navigator:

Click on the name of the diagnosis, then start entering comments in the space provided:

31
 There isn’t much space provided (what you see above is near the maximum—a little
Strategy longer than a tweet) but this is at least slightly less baroque than actual problem-
oriented charting (one click instead of two to start), and you get all of the text with
guide “.diag”:

Progress notes:
mechanics of your
charting strategy

Use NoteWriter (or parts thereof)

NoteWriter was designed for people who prefer clicking boxes to typing text. So long as
you’re quicker clicking than typing, and don’t mind giving up some flexibility, it’s a
reasonable way to write notes, and it’s been improving over time. When considering
NoteWriter, begin with the vocabulary:

• SmartBlock. A specialized SmartLink used in NoteWriter. Instead of bringing in

system information like the current date or the medication list, it calls up an
interactive form you can click in to document findings. There are SmartBlocks
for HPI’s, Reviews of Systems, Physical Exams, and Procedures. These forms are
defined at the system level. While you can type SmartBlock SmartLinks in a note
(like “.ROSBYAGE”), you’ll usually use them from a system-defined note
template, or your own SmartPhrases (as shown below).
• SmartBlock macro. You can save a set of predefined findings in a SmartBlock as
a macro. For example, if you see a lot of folks with fibromyalgia, you might save
a standard fibromyalgia exam as a macro for later use. You can make separate
macros for Epic’s pre-defined age ranges (see footnote 17 below) and by sex, so
you can have one version of, say, a general physical exam for teen boys and
another for adult women.

If you’re using Epic in non-widescreen mode, you can create either regular notes or
NoteWriter notes, depending on which button you use:

But in the widescreen view, or non-widescreen view with your note docked in the
sidebar, you may get only the Create Note button, which will make either regular notes
or NoteWriter notes depending on what’s in your note template. In reality, you’re using
NoteWriter either way; you just get to decide if you’re going to use its features—namely
SmartBlocks.

32
Strategy
guide

Progress notes:
mechanics of your
charting strategy If you use the dropdown arrow next to the Create Note button, you’ll see system-
defined NoteWriter templates:

So long as your note is in the sidebar, you can use your own templates in a SmartPhrase
complete with the magic that makes use of NoteWriter. The magic—the markers that
insert those checkbox HPI’s, ROS’s and physical exams in your note—is in the
SmartBlocks. They are typically highlighted in brown:

SmartBlocks cannot be deleted (though that capability is promised for Epic 2018), so use
care where you place them. Epic 2017 adds the capability to add your own speed
buttons for the HPI (either universal or based on Chief Complaint). It also has a narrative
HPI box on top of the HPI SmartForms. But, as in earlier versions, you can only have one

33
 narrative no matter how many HPI SmartBlocks you use (e.g., for diabetes,
Strategy hypertension, and depression). And, as of Epic 2017 you still you can’t use any
formatting (like boldface or bullet points) in a NoteWriter HPI SmartBlock or narrative.
guide
Some people may find that using NoteWriter for an HPI makes sense. I find it makes
notes sound like they were generated by a humorless robot. It may be most appropriate
Progress notes:
for urgent care where there’s usually only one HPI element.
mechanics of your
charting strategy

Many people who routinely use NoteWriter free text their HPI, then use NoteWriter for
the Review of Systems and exam. Simply skip the HPI SmartBlock by not pressing its
button in the toolbar, and type an HPI by yourself:

34
Strategy
guide

Progress notes:
mechanics of your
charting strategy

NoteWriter macros
The real power of NoteWriter is in macros, where you can store different versions of
standard Reviews of Systems and physical exams. For example, you might have an ROS
and/or physical exam for adults in for follow-up visits, and then a few others for adults
and children with colds. To set these up, check the appropriate boxes for the ROS
questions you typically ask for a given sort of visit, and then use the Pencil dropdown
menu. If you use the “Create macro from current data” button you’ll generate an ROS
(or Physical exam) based on the buttons you’ve already pushed:

Note that (in this case) your SmartBlock macro will be restricted by age17 and sex:

17
Epic’s default age bands are 0-1 years, 1-5 years, 5-13 years, and 13+ years.
35
Strategy
guide

Progress notes:
mechanics of your
charting strategy

If instead you use the next option, “Create new macro” (not creating one from current
data) you have to wait to push the buttons for ROS or exam elements, but the macro
won’t be restricted by sex, and can be used for both males and females.

Either way, you’ll end up in the SmartBlock Editor, where you can fine-tune the
contents, determine if this is a default macro you want to apply to all of your
NoteWriter notes, and share it with other users in the Owners/Users tab:

The “Set as primary macro” checkbox on the bottom simply seems to push this macro to
the leftmost position on the toolbar for a given age range as of Epic 2017. (In Epic 2014,
which had a macro menu as a toolbar, the primary macro was the one applied if you
clicked on the menu button.)

Eventually, you’ll end up with a library of macros you can access from the toolbar on the
top of the SmartBlock:

36
Strategy
guide

Progress notes:
mechanics of your
charting strategy

You can apply multiple macros by pressing one button, then another. (This will add in
items, but won’t change old ones, so if you apply a URI physical exam macro that says
“No wheezing” then an asthma one that says there is wheezing, your exam will say “No
wheezing” until you change it by hand.

You can rearrange the order of the macros on the toolbar in the Macro Manager (Epic
menu > Tools > SmartTool Editors > Macro Manager):

If you’re using the Macro Manager outside of a visit, select a SmartBlock set to edit in
the first box. Common ones include “Review of systems by age” and “PHYEXAMBYAGE.”
Besides rearranging, you can hide (or delete) SmartForms you don’t want to use, and
you can use the Owners /Users tab to share your SmartBlocks with others. (You can’t go
out and grab them yourself, so if you want to make use of someone else’s set, you’ll
need to ask them.) Also, you can’t yet duplicate your male 13+ year old “Low back pain”
SmartBlock to a female version as of Epic 2017, so you either will have some setup to do
(duplicate the low back pain exams for men and women if you created them with sex
restrictions), or you need to find someone who has done the work and is willing to share
their macros with you. You can make a SmartBlock macro without the gender noted, so
it will show up for men and women, as noted above. You can also make SmartBlock
macros that aren’t for specific age ranges, so long as the SmartBlocks allow it (in
general, dynamic SmartBlocks, like PHYEXAMBYAGE, require an age range).

Putting SmartBlocks in SmartPhrases

To make your own note templates (stored in SmartPhrases) with NoteWriter
SmartBlocks, simply insert SmartBlocks as you would SmartLinks in the SmartPhrase
manager. Here, I’m defining a SOAP note with SmartBlocks:

37
Strategy
guide

Progress notes:
mechanics of your
charting strategy

The two likely SmartBlocks you’re going to use are ROSBYAGE and
PHYSICALEXAMBYAGE, but notice there are also SmartBlocks for specialists above with
specific tools for cardiologists, plastics, neurology, OBGYN and orthopedics. You can also
use the @HPI@ SmartBlock, so long as you want to blow past my warning that it can be
hard to write a readable note with it. Once you have a SmartPhrase with SmartBlocks in
it, you can make a button for it in the progress note toolbar (or just type it, like .SOAP):

38
 Finally, there are Procedure SmartBlocks, defined at the system level (all accessed by
Strategy the @procdoc@ SmartBlock SmartLink). The particular ones that come up may be
determined by your specialty:
guide

Use Send Message

QuickActions

When you complete the work of setting up a bunch of ROS and Physical exam
SmartBlock macros, you should be able to quickly record exams and ROS’s with a pre-
defined library of macros, and document by exception.

Use Send Message QuickActions

If you work in primary care, you are in for the long haul (hopefully) with your patients,
which means you need a mechanism for ensuring they get longitudinal care. Epic will
take care of some basic items for you in Health Maintenance, so for common tasks like
mammograms and A1c’s that occur more or less at regular intervals, you’re set. But for
your patients with thyroid nodules requiring an annual ultrasound for which there is no
Health Maintenance plan, or your adults with an abnormal chest x-ray who need a 6
week follow-up film, it will be helpful to have a mechanism in place to act as a reminder.

One possibility is to “postpone” your chest x-ray result for 6 weeks so it shows up later
on as “new” with some comment about your plan in it. Because I worry about these
getting lost in a sea of results, I prefer Send Message QuickActions. These are simply
templates for staff messages, with a pre-set recipient (you can use yourself or a staff
member) and with pre-defined time intervals. Once set up, Send Message QuickActions
are accessible from the More Activities menu. (You can use these from the In Basket,
but then you have to attach the patient’s chart to the message yourself.)

39
Strategy
guide

Use Send Message

QuickActions

Send Message QuickActions from More Activities menu, Epic 2014

Send Message QuickActions from More menu, Epic 2017

You can also use Send Message QuickActions from the In Basket itself, under the New
Msg dropdown menu:

40
Strategy
guide

Use Send Message

QuickActions

Set up a Send Message QuickAction by using the QuickAction Manager dropdown menu
in the In Basket:

You can also save any Staff Message as a Send Message QuickAction by using the “Save
as QuickAction” button in the lower right corner:

41
Strategy
guide

Use Send Message

QuickActions

Set up the QuickAction as follows:

 Name the menu item. (That is, what you put here ends up being a button on your
Send Message QuickAction menu in the In basket, as well as the More activities > Send
message submenu from a patient workspace.)

 Put in your own name as the recipient (or your MA pool, if you’re confident with
delegation, or make versions for both circumstances).
42
  Put in a Subject line for the reference of your future self.
Strategy  Set a delivery time. Here, for example, we’re using 6 weeks in the future. Other
guide possible shortcuts are listed above.

You can edit existing QuickActions by clicking on the Manage QuickActions menu button
Use Send Message (instead of using the dropdown, as shown above), which gets you into the QuickAction
QuickActions Manager:

You can make new QuickActions using the upper left “New QuickAction” menu, or
double click on existing ones to edit their name, content, and delivery date. You can
create new versions of existing QuickActions by editing the button name and using the
Save As button:

43
Strategy
guide

Graphics in your AVS

Graphics in your AVS

Some of your patients, including the less literate or non-native English speakers, may
benefit from pictures in their After Visit Summary. For example, they may need a picture
of what generic Miralax looks like to find the right powder in the supermarket for their
bowels. You can copy and paste images directly from the Internet into the AVS, but it’s
probably best to put these in a SmartPhrase for easy access and to limit the number of
graphics Epic has to store forever. Better yet, use the SmartPhrases of an expert user on
your system. See the instructions in the Reference guide, under SmartPhrases with
graphics.

Use Chart Search

If you think of Epic as a big shoebox with all of your patient’s x-rays, lab results, and
progress notes crammed inside, it would be nice if there was a quick way to find stuff in
it without going from one item to the next. Have you looked in the upper right hand
corner lately?

Chart search: it’s been lurking there all along (since Epic 2014)

You probably have patients with a habit of saying things like “Remember when I had
that back pain 2 years ago, and you gave me that stuff with the thing? The blue stuff?
44
 And the white thing? That really worked. I need that again.” Type “back pain” in the
Strategy Search box on the upper right:

guide

Schedule your own

appointments

You’ll get a context-included list of relevant progress notes, medications, imaging and
orders. You can even find lost Epic menu items by typing them in there, like the pesky
Preference List Composer—where did I leave that?

Schedule your own appointments

This isn’t for everyone or every happenstance, but in some circumstances it may make
sense for you to set up your own patient appointments:

• Ensure appropriate follow-up when you’re taking call or discharging a newborn;

• Avoid stacking challenging patients together in your schedule.

From a patient workspace, go to More Activities > Schedule > Quick Schedule (or, use
the Appointment Desk, detailed in the strategy guide):

45
Strategy
guide

Schedule your own

appointments

 Department you’re scheduling in; defaults to the home department of the current
user. If you’re scheduling into someone else’s department, you can change it here. (If
you put in a user who is in another department, Epic will make the department name
match the user automatically.)

 Choose a visit type. You can use the magnifying glass or select an abbreviation (like
OVR for office visit regular, OVE for office visit extended, WELL for wellness visit).

 The provider you’re scheduling with. Defaults to you, if you’re the PCP.

 The date of the appointment. You can type it in here, or use the calendar button
inside the same box. Uncheck the Skip full day box at  if you think you might need to
double book or put in an appointment outside regular office hours.

 The “Jump to full appointment entry” button should be used if you need to schedule
other resources (like a procedure room or colposcope) or schedule a recurring
appointment.

 You can click on an open spot in the schedule to set the time of the appointment, or
type in the time at . The length defaults to the default for the visit type at , or you
can put in a custom length. Green spots are open, yellow spots are filled but have
available double-books, and red spots are totally filled or unavailable (but you can still
sometimes book into them if the number of open slots is more than 0, like at lunch).

 The appointment notes describe what the visit is for, like “AWV” or “Newborn check”
or “Follow-up hyperglycemia.” The provider will see these on the schedule so they know
what the patient is coming in for. Don’t skimp.

 Uncheck the “Skip full day” box if you need to double book or be sure a patient gets
in on a certain day (even if it’s full). The arrow keys navigate back and forth among

46
 days—the next or previous open day if the box is checked, or the next scheduled day
Strategy otherwise.

guide  Press the Schedule button (it will turn from grey to active once you have the
minimum necessary boxes filled in) when you’re ready to set up an appointment, then
follow the prompts.
Schedule your own
appointments You may then get taken to a screen to confirm the patient’s demographics (address,
phone number); just press the Finish button on the lower right:

Cancel appointments
If you need to cancel an appointment, use Patient Station (on your top toolbar) to get to
the Patient chart, and get to the patient’s Appointment Desk under the Actions menu on
the upper right:

From here, you can see Future appointments on the first tab (halfway down the screen),
and use the Can/Rsch button to Cancel (and possibly Reschedule) them:

47
Strategy
guide

Schedule your own

appointments

Once you click the Can/Rsch button, you can verify which appointments you’re
canceling (since you can select more than one), and choose to plain old cancel them or
jump to the scheduling activity to reschedule afterward:

You should put in enough of a cancellation reason on the bottom that colleagues can tell
what happened in case a patient cancelled a potentially important appointment.

You can also look at Past appointments (second tab above, including No shows and
Cancellations) and examine the Pie Chart of Irresponsibility on the upper right, which
shows your patient’s percentage of No Shows. Maybe put those folks last on a Friday. Or
consider a Visit type flag.

You can double click on appointments here in the Appointment Desk to get an audit log
of scheduling, figuring out, for example, who double booked your complicated
demented non-English-speaking patient over lunch.

48
 Please don’t stick fake patients in your schedule or make your well child checks 2 hours
Strategy long, lest someone decide to take this capability away.

guide Customize schedule columns

Staring at your schedule doesn’t have to be just for figuring out if you ever might leave
clinic on a given day. You can also set it up to tell you valuable information about your
Schedule your own
patients:
appointments

Like you, I have the patient’s name, visit type, and appointment notes around. I also like
to have the time they checked in and roomed time so I can see how many abject
apologies I may need to make, a Gestational Age column since that helps me figure out
what topics to discuss with my pregnant patients, a Preferred name column (especially
handy for transgender patients), and a column showing whether or not Health
Maintenance items are due. You can even keep multiple layouts around; I have one for
newborns that includes Days of Life and birth gestational age, as well as total bilirubin.
These schedule column templates show up in the schedule activity on the left as folders,
and each actual schedule you pop in those folders will show up displaying that folder’s
columns:

Epic 2017 schedule configuration Epic 2018 schedule configuration

49
  The Open Slots button, when on, lets you see where you have gaps in your schedule
Strategy instead of cramming together. Find out when you can pee! (Unless of course you get a
surprise walk-in.)
guide
 The Dept box defaults to your own department, but you can put in other
departments here too, and find out what they’re up against.
Schedule your own
appointments  The Create button creates a new schedule folder under My Schedule. You might use a
different column template here, or grab a few of your co-conspirators from the
department schedule below to see the schedules of your teammates along with your
own. The gear button edits an existing folder’s column template; the X button (red
minus sign in Epic 2018) deletes a folder from My Schedule.

 The folders under My Schedule include your default one (normally named after you);
you can change the default with a right click. It also includes any custom folders you
make.

 The folder with your department contains names of your colleagues and yourself. You
can drag and drop them from here to other folders. You can even put in another
department name in the box at  and put someone from a different department in one
of the My Schedule folders. Note that the only names that show up in the department
folder are those with scheduled patients on the selected day.

To edit the columns in an existing schedule, highlight the folder (not the names inside
the folder), and click on the gear button as shown above:

Epic 2017 Epic 2018 schedule folder configuration

 Give the schedule configuration a name, like “Default,” or “Infants” or “TGIF.”

 The left column (upper box in Epic 2018) shows column headings available. You’ll
notice some look like exact duplicates but work differently (like some Name columns are
all UPPER CASE, but other identically-appearing ones are a much more legible Title
Case). The Descriptions are not always helpful, so there will be some trial and error
here.

 The right column (lower box in Epic 2018) shows headings currently displayed, and
the arrow buttons rearrange their order. Don’t go too crazy, or your schedule will be as
wide as the Mississippi.

50
  You can use the Copy button to copy a set of other column headings into this
Strategy schedule folder. Note that the search space includes every schedule configuration
available in this instance of Epic, so you can trade with friends—so long as you know
guide exactly what they called their schedule configuration.

Customize your Customize your toolbars and workspace

toolbars and When you’re taking off a toenail or delivering a baby you probably have preferred
workspace positions for your instruments. You want quick access to the things you may need right
away, and it’s helpful to know where less oft-used items are in case things get
complicated. Epic lets you customize the locations of its tools in a similar manner.

Customize the main toolbar

The toolbar is the list of activities that are not necessarily patient specific, laid out at the
top of the Epic window. The manner in you which customize your layout got more
sophisticated in Epic 2017:

 You may have a Personalize menu on the toolbar; if not, it’s under Epic menu >
Personalize.

 The wrench should always be hanging out near the top right of your toolbar; it’s the
same as the Customize My Toolbars option at .

51
Strategy
guide

Customize your
toolbars and
If you get to the screen above, click Accept to exit, or on the legend “Drag things to
workspace
where you’d like them” to start dragging:

You can drag items from the illustrated of the Epic menu (not the Epic menu itself) to
the top toolbar, move items around in the top toolbar, and move items you hardly ever
use to the oubliette18 of the Rarely Used submenu. If, for example, you don’t care to
look at patients’ billing balances, you might stick Enterprise Billing in there. You can
always get it out again later.

If you’re curious, my top toolbar items are Patient station, My Reports (for Reporting
Workbench), UpToDate, Patient Lists, SmartPhrase Manager, and (because I do OB) L&D
Grease Board.

Choose the startup activity

Epic 2017 introduced the ability to choose the activity that comes up by default when
you log in. You might like to start out in the In basket, for example, instead of your
schedule:

18
A secret dungeon with access only through a trapdoor, from the French, late 18 th century.
52
Strategy
guide

Customize your If there is a star in the upper right corner of the activity, you can click it; that will be
toolbars and where you end up upon logging in henceforth.
workspace
Customize the patient workspace
When you’re in a patient workspace (meaning, in a tab with a chart open), there is
counterpart to the top toolbar where general activities hang out. It’s the patient
workspace Activity list, a patient-specific list of activities on the left side of the window,
and with additional friends ,listed under the More menu on the lower left (known as
More Activities prior to Epic 2017). The patient workspace has its own customization
wrench, which is either right above the More menu on the lower left…

…or, when Epic wants to save vertical screen real estate, it moves in with the More
menu:

53
Strategy
guide

Customize your
toolbars and
workspace

Click it, and you get the following equivalent to the toolbar customization activity, as of
Epic 2017:

Whoever wrote this seemingly straightforward activity included a lot of sophistication,

and crafted it lovingly. While I think it is pretty self-explanatory, I point it out here to
encourage you to use it.

 This button becomes active once Epic collects enough statistics about which patient
activities you’re using most often. Click here, and it will rearrange things in a way it
thinks you might find useful.

 The left hand column represents the contents of vertical list of activities that show up
when you are in a patient chart; put more frequently used here. Don’t put in too many,
or you’ll end up with time-wasting scroll buttons. My particular choices: Chart Review,
History, Problem list, Medications, Immunizations, Communications, Order Review,
Encounter, Patient message Review, Health Maintenance, Quick Schedule, Care Teams,
Graphs, and Patient List Membership.

54
  The right hand column represents the contents squirrelled away in the More menu
Strategy on the lower left; less often-used items go here.

guide  The Rarely Used folder target is where you can move items you don’t have much use
for, so they’re out of the way. Perhaps Document List, Patient Services/Educ, Chart
Request and BPA Review might end up here.
Consider the
Widescreen view  If in your enthusiasm to rearrange the furniture you can’t find the sofa and chairs
anymore, click here to return to the manufacturer’s default layout.

Consider the Widescreen view

Epic (as of version 2017) has two different ways of looking at most visit navigators. The
traditional view has a bunch of “activity” buttons on the leftmost side of the window, all
of which refer to the current patient. Next to that is a column of “navigator sections”
which allow you to record items for the current visit encounter, like vital signs and
medications. Some items are seemingly duplicated between the list of activities (like
Medications) and the visit navigator (like Meds & Orders), but they are always a little
different—older and newer ways of manipulating the same information.

Traditional, non-widescreen view (Epic 2014)

In the Widescreen view, most of the activities buttons disappear, though you can still
get to them under the More (previously known as More Activities menu) on the lower
left. And the visit navigator section buttons get glommed together under larger “fat
buttons.” For example, the new Plan button includes the Problem List, Visit Diagnoses,
BestPractice Alerts, Meds & Orders, and SmartSets sections. Those buttons move from a
column on the left to a row on the top of the workspace, below the banner:

55
Strategy
guide

Consider the
Widescreen view

Widescreen visit navigator (Epic 2017)

The goal is to provide you with a bit more horizontal screen real estate. This helps to
avoid your needing to scroll around and move to different screens. To make the
Widescreen View work, you’re going to need a large monitor (Epic recommends 24
inches or more, as above).

Among the potential downsides:

• You’ll need to rebuild your muscle memory to look for navigator sections on top
instead of along the side;
• You can’t see all the navigator sections at once; much of the time, you’ll need to
click the correct fat button first, then the navigator section it lives under. This
may take getting used to for widescreen novices, and may put many functions
two clicks away instead of one. A lot of that grief can be sidestepped, however,
by using keyboard shortcuts, as noted above.

56
Reference guide Reference guide

Care Everywhere
Care Everywhere19 is the platform Epic uses to exchange progress notes, labs, imaging
and other study data amongst different instances of Epic (like Providence and Swedish),
other vendors’ systems (like the Oregon Clinic, on Centricity as of press time), other
outside entities (like the Veterans Administration), Health Information Exchanges (HIE’s)
which serve as a hub for multiple systems, and Health Information Service Providers
(HISP’s, like SureScripts, which can transmit information from pharmacies). It can even
get information from compatible institutions in a difference country, which Epic
considers to be transmitted on their “galaxy-wide network,” so you can tell they’re
planning for future expansion.20

Care Everywhere can both push information to an outside system (such as when a
patient goes to the University for a consultation, and they push back a consult note with
a Summary of Care document), and you can pull information from outside systems too
(to get old office visits when a patient transfers care to you).

First steps: Request Outside Records

If you have a patient who you think has outside records, you’d go to the Request
Outside Records activity from a patient workspace (inside their chart).21 If a patient has
no existing outside links, the initial screen looks like this:

19
Note that Epic styles this product with two words. Maybe the space in between Care
Everywhere represents the gulf the electrons travel across, whereas something like BestPractice
delineates just how close your practice is to best.
20
For further reading, see the article about the Interplanetary Internet, which details how delay-
tolerant protocols can mitigate the problem of latency due to limitations imposed by the speed
of light at interplanetary distances.
21
Epic will want you to make the request to view records from a relatively recent encounter (it
was within the last 2 days in our Epic 2014 setup, and now it’s the last month in our version of
Epic 2017). This is so there’s a place for Epic to record the audit trail of your comings and goings.
Reference
guide

Care Everywhere

If the patient has already been successfully linked to at least one outside organization,
Request Outside Records will show existing links, and let you request new ones:

You can click the Query New Organization button to set up new links. Either way, you’ll
be prompted to give a reason for the request (I like to use Treatment or Care
Coordination). Epic then tries to match up your patient with one in each outside
organization. The patient matching procedure tries to be careful not to match up two
patients with similar names who aren’t really the same person, while also letting you
58
 match up one person whose name might appear a little differently amongst different
Reference institutions. Epic comes up with a confidence score, based on name and birthday (which
count for a lot), zip code, phone numbers, sex, city, social security number, and zip code.
guide If there’s no obvious match, or more than one possible match, you’ll get a message like
this:
Care Everywhere

It prompts you to call the outside organization, and match up the patient with a real
human. The outside organization’s representative will generate a “Care Everywhere ID”
on their end to identify the precise patient the two of you came up with, like “KNW-23-
2346.” Type that in the box shown, and the patient should be linked right away.

If even that doesn’t work, chances are there’s something about the potential match that
Epic still doesn’t like, like a difference of spelling of the last names. Don’t get off the
phone with the remote organization until you’ve worked it through. For example, if you
are reconciling Francisco Vasco de Gama, ask them to spell the last name. If they have
“Vazco de Gama,” go to the Demographics activity (Snapshot > Overview >
Demographics or Chart Search > Demographics) and change the spelling of the local
name. (Epic will keep the old spelling as an alias.)22

When Epic thinks it has a patient match, it will prompt you to verify it, highlighting
potential discrepancies in yellow:

22
I suppose you could also try to convince the remote organization that everyone knows
Francisco Vascso de Gama, Admiral of the Seas of Arabia, Persia, India and all the Orients, Second
Viceroy of India, First Count of Vidigueira was a Portuguese explorer who would have been highly
unlikely to use the Spanish-style ‘z’ orthography. As you know, however, HIM tends to stand their
ground without specific documentation right in front of them.
59
Reference
guide

Care Everywhere

Epic is pointing out to you reasons that maybe this isn’t the same guy. If you’re certain it
is, click “Yes — Correct Patient.” Otherwise, don’t: if you link a patient improperly,
you’re going to have to enlist your help desk to unlink the records and probably deliver
flowers at your own expense to whoever’s record you accidentally linked up.

Supposing you agreed to link the patients, click on the View Chart button, which shows
all of the outside information (from one or more institutions) in one place:

That place is the Care Everywhere activity.

Care Everywhere activity

You can get into the Care Everywhere activity from the Request Outside Records activity
(as shown above). Or you can click on the Care Everywhere button that will show up on
the left side of a patient workspace once they have any outside links sets up.

The Care Everywhere activity starts off by trying to sync up the headers from outside
institutions, then displaying boxes summarizing what it found:

60
Reference
guide

Care Everywhere

By headers, I mean you’ll get a list of documents in the Documents tab (with the
creation date, type, department, author, and associated diagnoses), but you’ll need to
double click on each one to download the rest of the contents. Once a document is
downloaded, it will show up with a check mark on the left:

Note that Epic reconciles a lot of information (the Problem list, Medications, Allergies,
Immunizations, Chart notes; and to an extent labs, imaging and other studies). Some
information, though, is not reconciled into the local record. Instead, it’s readily visible
only in the Summary tab of the Care Everywhere activity, like Family history and OB
history. These may be reconcilable as discrete data in future versions of Epic:
61
Reference
guide

Care Everywhere

Care Everywhere records in Chart review

As of Epic 2017, Care Everywhere notes can be displayed in Chart review > Encounters,
alongside local encounters:

 The Care Everywhere sliding button in Chart review plays several roles. You can slide
it to Off to hide remote documents. It will show an exclamation point in a triangle to
draw your attention; if you hover over the slider it will let you know what’s up:

62
Reference
guide

Care Everywhere

Most commonly, it wants to let you know it’s detected outside information that has not
yet been reconciled into the local chart; click on the blue “Request Updates” link to sync
it up. You can click on the “Reconciling outside information” link to get to the
eponymous activity (detailed below).

 Information for individual encounters. Encounters where just the header

information is available (name of provider, description, date and encounter type) shows
up in gray type. Once an encounter is reconciled, the header and Care Everywhere icon
turn darker. If you hover over the icon you’ll get a tooltip telling you the name of the
outside organization.

 The “with” column shows the specialty and provider name. If you hover over the field
in the “with” column you’ll get the full name of the department and outside provider.

63
 Viewing reconciled information
Reference
guide

Care Everywhere

If you’re in Chart review > Encounters, you can see the outside progress notes, chief
complaint, lab and imaging results, and patient instructions. Note that if the notes had
any fancy formatting (boldface, tables, colors) those are flattened out to plain text (as of
April 2017). Lab and imaging results are only viewable here in the Encounters tab and in
the Care Everywhere activity; they are not yet integrated into the local Labs and Imaging
tabs. You can navigate around the note with the “Jump to Section” menu in the note
preview.

Reconcile Outside Information activity

When Epic notes that a linked organization has updated their version of the Problem
List, Medication list, Allergies or Immunizations, it will mark the local version as out of
date. You’ll get a prompt at the top of appropriate navigator sections (like the Problem
list) or activities (like Immunizations) to reconcile the information so it’s up to date:

If you click on the “Go Reconcile” button, you’ll end up in the Reconcile Outside
Information activity:

64
Reference
guide

Care Everywhere

This is a blessing dressed up as a curse for many clinicians. Do you remember the days
when you’d admit an incoherent patient without available family members on a Friday
evening, and you’d have to wait until Monday to get someone at their clinic to fax over
their chart notes? Invaluable information is now available at the touch of a button
(okay, maybe a few buttons). Isn’t it great to know that your new patient with diabetes
was also previously diagnosed with coronary artery disease and renal insufficiency and
hyperosmolar coma? But keeping long lists of critical information (with no room for
error) synchronized among many institutions isn’t just a fascinating computer science
problem. It also means that clinicians will often be asked to review potential changes in
outside problem and medication lists. It’s amazing that you can access, for example, all
the problem-oriented assessment and plan notes from an outside organization’s CHF
problem, but that means each time a problem gets updated remotely (even in a
telephone encounter) you’ll be asked to make sure everything on the problem list still
matches up. To get an idea of how fast the hamster wheel is spinning behind the scenes,
check out the “Patient document history report” (Epic > Reports > Care Everywhere).
One visit to an outside hospital for a single patient does all this in the background:

65
Reference
guide

Scheduling

We can expect over time that the algorithms will get more sophisticated, recognizing
that “BID” over at the University is the same as “twice daily” in your chart, and problem
reconciliation already improved from Epic 2014 to Epic 2017 (Epic now distinguishes
between new problems and updates). Personally, I think it’s worth the time to reconcile
the information whenever you’re otherwise updating the chart, but I’m sympathetic to
clinicians who find it’s a slog.

Scheduling
Scheduling your own appointments
Sometimes, when you’re on call or discharging patients from the hospital, it’s handy to
set up follow-up appointments. The Strategy Guide (above) reviews how to do this.

Appointment Desk and Visit type flags

The Appointment Desk lets you make appointments (easiest from the “Quick Appt”
button), see upcoming and past/cancelled appointments, and access the Patient
Options menu typically used by front desk staff to set up patient and visit flags, detailed
below.

To get to the Appointment Desk, depending on how your Epic is set up, go to Patient
station, select your patient, and click on the Actions menu on the upper right:

66
 Epic 2014 Appointment desk: available from Patient Station > Actions menu

Reference
guide

Scheduling

Epic 2017 Appointment desk: available from Select encounter > Appts. If you don’t see Appts, check the
“three dots” expansion menu on the upper right (not shown here)

There’s a lot you can do from the Appointment Desk, most of which you don’t need as a
clinician. I’m listing your options here for reference (so you know what’s possible). I
think providers can reasonably use “Quick Appointment” and perhaps “Patient visit type
modifiers.”

Epic 2017 Appointment Desk

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Reference
guide

Scheduling

Epic 2018 Appointment Desk

 Make appointment lets you search for openings for one or more providers, and make
recurring appointments (such as for OB care). Providers won’t typically use this. “One
Click” appointments lets you search for “solutions” defined in your department, such as
“Office visit with PCP” will look for openings in the next few days with the patient’s PCP.

 Walk-in works a lot like Quick Appointment (described in the Strategy Guide): it
looks for appointments today, defaulting to the PCP. Quick Appointment is available in
Providence’s More (Activities) menu, so you can get to it via the patient workspace and
mark the activity with a star. Quick Appointment checks the “Skip full day” box by
default and lets you use “Use patient preferences.” (Walk-in appointments ignore the
patient’s preferences for days they prefer to be seen, because we assume they want to
be seen today and don’t care if you’re full.)

 Class appointments, if you’re set up to use them, let you put a bunch of patients in a
scheduled class that might, for example, start February 2 and end April 2 on Mondays,
Wednesdays and Fridays at noon. Classes will show up in the schedule like any other
appointment:

If your department is using Wait lists, you can add patients to a list for one or more
specific providers with high, low or normal priority with preferred days and times.

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Reference
guide

Scheduling

A support staff member then needs to “work” the wait list to schedule patients based
on their preferences.

 History lets you run a report of a patient’s previous appointments and see when they
showed up, cancelled, or no-showed. It generates plenty of pie charts. Itinerary
generates a printing list of directions to various clinics, useful especially if your patient
has back-to-back appointments in different places.

 Locate tells you where a patient is based on the location of the appointment they’re
currently arrived at. Week view and Calendar display and allow printing of multiple
appointments a week or a month at a time. These would mostly be useful for patients
with a lot of appointments.

 Patient summary displays basic demographics about a patient; you can edit it to
change the addresses, language, phone numbers, email address and PCP of a patient.

 The Patient Options menu has a bunch of functions, including Visit types, described
below.

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 • Preferences lets a patient designate the preferred sex and language of a
Reference provider, preferred days of the week and times of day for scheduling, preferred
providers, and appointment reminder and communication preferences.
guide • Patient flags lets you set up notifications that go to certain people, like a case
manager, whenever a patient schedules, cancels, or no-shows an appointment.
Scheduling • Benefits lists insurance coverage information (also available from the banner).
• Referrals lists a summary of pending, authorized, and completed referrals.
• Print labels lets you print a patient label on a nearby label printer to stick on
specimen bottles or papers to scan.
• Patient messages can be set up that show in the Patient sidebar during
scheduling until the messages hit their expiration date. (Like, can’t come in
between 2-5 during the school year.)
• Patient Visit Type modifiers let you change the default appointment length for
a patient. For example, you can recommend (or insist) against regular office
visits but allow extended length ones, for all appointments or specific providers.
You can use the “Add/subtract/replace” column to change the scheduled
appointment by the amount of time in the length column, automatically adding
on 20 minutes for complicated folks or subtracting 20 minutes for chronic no-
showers.

• Patient recalls lets you add patients to a list of people to call after a certain date
to make an appointment. For example, instead of scheduling the next Annual
Wellness Visit a year out, you might put them on the recall list for a year out.
You’d set up a “New recall” with a Notification date (when a recall letter should
get sent), a Recall date (the approximate date the appointment should be
scheduled), and the Expiration date (when the recall is no longer valid). For this
to work, someone in your office has to “work” the recall list to actually make the
appointments.
• Patient FYI flags lets you create, edit and delete FYI’s, described below. When
scheduling, there’s a link to Flags and Messages:

 In the bottom pane of the Appointment desk you can see a schedule of future
appointments. You double click on an appointment row to get details (as in), which
shows who made or changed an appointment. In the Past appointments tab, you can
see cancellations and no-shows. Wait lists, Orders pending, and Referrals end up here
too.

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  The buttons on the bottom of the Appointment Desk are used by your support staff
Reference to link to the Registration activity (take my advice: stay out of there), work on Assigning
referrals (likewise), Check patients In or Out (providers don’t typically want to do this
guide unless you want to be responsible for collecting co-pays and verifying eligibility),
Cancel/Reschedule appointments (see above), Edit the appointment notes (like change
Patient FYI flags “F/u mood” to “F/u severe anxiety – GAD-7” or copy a previous appointment’s details to
a new future one.

Patient FYI flags

Patient FYI flags are alerts useful for scheduling, cross-coverage and patient care that
are visible by clinicians, nurses, schedulers, and on the ED trackboard.

Patient FYI flags may be visible (and accessible for viewing and editing) on the patient
banner (hover with the mouse to see flag types):

Or via More (Activities) > FYI. In the FYI activity, you’ll see existing flags which you can
edit, and you can make new ones:

Flags have detailed text, and an optional summary which will show up in lists instead of
the first part of the detail text if you fill something in:

In the bottom part of the activity, you can deactivate and see an audit log (“Show/Hide
History”) for each flag:

Common flags used at Providence include:

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 • Behavioral agreement, like “Multiple no-shows, cannot pre-schedule
Reference appointments; must come in before 10 am and wait in lobby to be worked in.”
• Blood products refusal indicates patients who decline blood products, typically
guide for religious reasons.
• ED Care Plan Alert details a collaborative care plan for the ED to use for
Care teams complicated or repeat ED patients.
• Foster care indicates a pediatric patient who is enrolled in the foster care
system.
• General is a flag that can be used to denote concerns for which there is no more
specific flag type.
• Medication agreement, showing a summary of controlled substances for which
the patient has a signed treatment contract and material risk notice, like
“Oxycodone 5 mg #112 q 28 days.”
• Palliative care plan includes details of palliative treatment plans.
• Patient dismissed / Patient terminated from PMG identifies patients in the
process or having completed termination from medical clinics associated with
the health care system; there may be details of violation of treatment
agreements, missed appointments, or failure to maintain a therapeutic clinician-
patient relationship.
• Security risk identifies patients who may be prone to violence or aggression, or
are persons of interest in security department bulletins or identity theft
investigations.
• Chart correction can help identify previously mis-identified patients; it also pops
up whenever you open a patient chart, interestingly.

Some flags are used to modify alerts or functions elsewhere in the system. For example,
the Disabled FYI will, when applied to a teen patient, will allow adults with a proxy type
of “Adult accessing diminished capacity teen” full access to their MyChart account,
instead of no access (which would otherwise be the case for 12-17 year olds).

Care teams
The Care Teams activity, available under More (Activities) > Care Teams, lets you assign,
re-assign, and end patient relationships with PCP’s and other team members:

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guide

Care teams

 You can switch PCP’s by putting a name in the PCP box, including re-assigning
patients to outside PCP’s if they have left your institution. (This may affect your quality
scores and receipt of CareEverywhere notifications, in potentially pleasing ways.) You
can change the default effective dates if needed so a patient can slide onto another
panel at a pre-determined future date.

 The End button removes a member from the care team. The nearby, downward-
facing expansion arrow shows the address of the provider. If you click the neighboring
date, you’ll see past updates and who was responsible for them:

 If you click on the name of the team member, you can look at or change some of the
details:

 You can note different types of relationships with providers, such as “Consulting
Physician” or “Case Manager.” Much of the time the right relationship will be defaulted
in for you. You can End a provider relationship by filling in the End box with a date, or
clicking the End icon above. You can also click Delete at  if the member was in error
instead of just leaving the team.

73
  For both PCP’s and consultants, you can decide what sort of notifications team
Reference members receive. PCP’s may want to be informed of all admissions on some patients,
whereas they may wish to leave most consultants alone for both admissions and results.
guide
Not all consultants will be available in the Provider directory when you’re trying to add a
team member. In this case, instead of searching for a provider in the Add box, just press
Letters (a.k.a, the
the “Add” button, then the “Free text provider” button on the lower left:
Communications and
Letters activities)

This will help keep track of providers, even though free-texted providers won’t be
available as recipients in the Communication activity.

Sometimes you’ll see episode-specific Care Team members in this activity. They are
view-only here—you edit them from within an encounter that is part of the episode:

Letters (a.k.a, the Communications and Letters activities)

Communications activity
Epic uses the Communications activity to create letters, though they don’t always end
up with the postal carrier. They can be printed, faxed, sent to the In basket of a
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 colleague on your instance of Epic or to their In basket in an outside instance of Epic (via
Reference “Outside provider messaging”). Unlike other encounters, they cannot be easily
addended; once you press the Send button, Epic figures they went into a federal
guide mailbox, where, as noted elsewhere, they cannot be retrieved.24

Letters (a.k.a, the

Communications and
Letters activities)

Communication activity in Epic 2017 widescreen view

Communication activity, non-widescreen view, Epic 2014

You can access the Communication Activity via the More (Activities) menu during a
patient encounter, or start a new Letter (Out) encounter from a patient workspace if
you aren’t currently in an encounter and don’t want to addend an existing one. You can
see above an advantage of the widescreen view: you can see the chart note while you’re
writing a letter. In Epic 2017 widescreen ambulatory visit encounters, the Wrap Up
section has a built-in communication activity, designed to let you write quick work
excuse (and similar) notes.

The key to making the Communications activity work for you is understanding its
workings, starting with configuring it with the wrench (next to the New Communication
button):

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Letters (a.k.a, the

Communications and
Letters activities)

 If you close an encounter or communications section with a letter in it that isn’t sent,
what should happen to it? Since sending “locks” the letter so it can no longer be edited,
I’d pend it.

 Often, you’ll route letters to support staff (so they can print the letter when ready
and send it for you). I like to route it to them as soon as I’m done, not waiting for the
encounter to close.

 Choose as a default the template you use most often. For me, it’s a simple blank
letter, e.g., “GEN TO PATIENT; BLANK.” This will be the template that pops up when you
click the “New communication” button. You can replace it with another template by
pressing one of the buttons you designate in  below.

 Set up a bunch of other common letter templates you can use. As of Epic 2017, you
can only use system SmartTexts for this, not your own SmartPhrases. You can always
customize the letters themselves once you open them. N.B.: these buttons won’t
actually show up until you close and re-open the activity.

 You can choose to send (print or send to an In basket) by default, or to route to

support staff. I think most clinicians will want to route support staff by default; choose
your local MA or pool here. If you work in multiple departments, you can choose
different default support staff for each department in .

Once you are actually writing a letter, you’ll get the following activity:

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Letters (a.k.a, the

Communications and
Letters activities)

 Step 1 is often forgotten: you always need to specify a recipient with these buttons
on top of the activity. The first button you push is the primary recipient; subsequent
buttons are Cc’d recipients. The Care Teams button contains all the members
designated in the Care Teams activity (More activities > Care teams). You can use the
box at  to search for recipients not found in the buttons, including free-texted
recipients (with arbitrary fax numbers—check your typing so you don’t end up in HIPAA
prison).

 Once you choose one or more recipients, you can click on their names to change the
delivery method. Print shows up as Mail; patients with active MyChart accounts show
that as an option; other recipients can use In Basket if they are available on this instance
of Epic, or Outside Provider Messaging if they have an account on another instance of
Epic, or Fax if they have a fax number). You can change who is the primary vs Cc’d
recipients, edit an address (mostly important for changing a fax number), and press the
X next to a name to remove a recipient. N.B.: As of Epic 2017, there’s no obvious way to
see if an Outside provider message got read.

 You can choose one template for a letter; if you choose a new one, all of your
previous typed contents will be removed. The speed buttons are defined in the
configuration activity shown above; you can use the Other button to choose another
template from among the system templates. You can have more than one letter per
encounter; you just need to press the New communication button each time, and you
can only edit one at a time.

 If you’re a clinician, you’ll leave your own name here. Support staff may start out
letters and may need to change the name of the person who’s writing it.
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  Include a reason for the letter. That’s what shows up in Chart Review, in case you
Reference need to go back and modify a previous work release or pet companion letter. There are
a bunch of built in reasons; the little piece of paper lets you add free text. For example, I
guide often use “Referral” as a reason, and I free text in the name and specialty of the
consultant.
Letters (a.k.a, the
Communications and
Letters activities)

Chart Review > Letters tab, illustrating why you want to put in Reasons for the letter

 Actual letter content goes here. In Epic 2014, letter content margins were set by
putting the whole thing in a table cell, which made copying and pasting selections a
pain; that’s easier in Epic 2017. Your letter templates can have a @CCLIST@ SmartLink
on top so the recipients’ name and address shows up the way you’d expect:

SmartLink Description
@CCLIST@ The list of recipients, including street addresses if
defined and the phrase “VIA Mail,” “VIA In
basket,” or “VIA fax” according to the method of
delivery
@CCLISTADDRESS@ The list of recipients along with their mailing
address (note: not all of these SmartLinks may be
available in your version, but you can always ask
that they be added)
@CCLISTFIRST@ The first recipient along with the address and
method of delivery
@CCLISTREST@ The rest of the recipients
@CCLISTLASTNOCRED@ The last name of the first recipient, without their
credentials, so you can address a letter as “Dear
Dr Smythe-Flintsock”
@CCLISTRESTNAME@ The names of the rest of the list of recipients

 Consultants especially may want letter attachments, such as the main content stating
only “Thanks for sending along this lovely patient and @his@ interesting presentation.

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 My progress note with findings and a plan are attached.” You’d use an attachment, like
Reference the “Outpatient” template, to attach the active progress note from this encounter.

guide  You’ll usually use the same routing options all the time. I check the box to route
drafts to my support pool, and check the “Keep as default” option so that my support
pool shows up with each letter. If you click on “Clean up letter” or “Recipient
Letters (a.k.a, the
information incomplete” the In basket message to your support staff will include either
Communications and
of both of those messages. If you click on the arrow next to the word “Instructions,” you
Letters activities)
can free text in additional information to include, like “send this along with a box of
candy.” If you check the “Wait for results” box, you’ll get a list of orders that have not
been resulted; clicking on one or more will hold the routing to your support staff until
those results are in. “Wait for transcriptions” works similarly.

Letters activity
In addition to the newer Communications activity, there is the older Letters activity,
available under More (Activities), at least in some installations. The Communications
activity only shows you letters from the current encounter; if you want to see previous
ones, you can gaze longingly at them in Chart review, but if you want to edit or delete
them, or void them (kind of like deleting letters already marked as sent, but not actually
sent), you’re going to have to go old school. The Letters activity can also copy old letters
into new ones, and void sent letters.

The Letters activity does not have fancy addressing options; you can route your letter,
but cannot denote any recipients except those who have desktops on your instance of
Epic. If you want to fax it to Slovenia, that goes in the routing comments for your MA to
figure out:

The Letters activity’s primary tab is “Attached letters,” which shows letters in the
current encounter. The next one, “All letters,” gives you options to Edit, Copy, and
Delete letters from any encounter:

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Letters (a.k.a, the

Communications and
Letters activities)

 Choose between viewing Attached letters (ones attached to this encounter) or All
Letters (any encounter), and the radio buttons just below can filter out letters that are
already sent. If you’re making a new letter, select a template below and then the New
button above.

 You can Edit unsent letters (the button changes to View if you highlight a sent letter).

 If you want to copy an old (even sent) letter to a new one for editing, do that here.
The new-fangled Communications activity won’t do that!

 You can Delete unsent letters. If a letter was marked as sent but it actually only made
it as far as the recycling bin, this is where you can mark it Void (also not obviously
available in the Communications activity).

Communication Management navigator section

As of Epic 2017, the Epic 2017 Foundation system has a Communication activity shrunk
a bit and cleverly placed in the Wrap-Up section of the widescreen visit navigator:

You can start new letters from here, or edit old ones; either way, instead of taking over
the whole window they appear in the context of the visit navigator:

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SmartTools

If you’re writing a referral letter to a consultant, you’ll still need to switch back and forth
between Chart review and Wrap-Up to gather together information to put into a well-
written request for consultation. (You can see with all of those button on top why it
might not have been easy to cram into the sidebar.) Still, it’s a bit easier to get to.

The Letters activity no longer appears in the Epic 2017 Foundation system, but you
should still be able to use it if it’s configured to show up by your Epic analyst friends. Tell
them to keep it around until Communications gets its own Void button and access to
previous letters!

SmartTools
The SmartTools discussed here are the ones most useful for end users (see SmartBlocks
in the NoteWriter section):

• SmartPhrases, which store a block of text (and can include formatting, tables
and graphics) for use as progress note templates, patient instructions, and
letters; you can define and share your own;
• SmartLinks, which pull information out of Epic into a note, like the current date,
lab result, or answers to a questionnaire;
• SmartLists, which, when placed in a note, let users select from a list of options
of text (like “Yes” and “No,” SmartLinks, or other SmartLists). SmartLists can also
file data into an Epic database, like your attestation that you screened a patient
for alcohol abuse.

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 SmartPhrases
Reference A SmartPhrase stores a block of text which you can access with a “dot” when you’re
typing, like this version of .SOAP used as a note template:
guide
@CC@

SmartTools Subjective
•

ROS

@HMLIST@

@ALLERGY@

Objective
@VS@

@XGEN@

Assessment/Plan
@PROBAPNOTES@

SmartPhrases encapsulating other SmartTools

Note that the above example contains other SmartPhrases (and SmartLinks),
surrounded by (“delimited” by) @ signs. If you use the SmartPhrase manager to make a
new phrase containing a note template, and type “.VS” Epic will replace that
automatically with “@VS@” for you. In general the dot (period character) means
replace something right now, and @ sign delimiters means do it later, so you get the
current vital signs of your patient, and not what they were when you first defined your
SmartPhrase.

Note that SmartPhrases can contain other SmartPhrases. Here, “@XGEN@” refers to
another SmartPhrase, containing the following:

Gen Well-nourished, appears stated age, no acute distress

Why would you want to do that? So that if you use @XGEN@ in a bunch of templates
and make a change to it, you can just change the XGEN SmartPhrase itself, instead of all
the templates that contain a line for the general exam element. If you shared this
SmartPhrase with another user who didn’t have @XGEN@ defined on their own list of
SmartPhrases, however, it would just show up as @XGEN@ in their note.

SmartPhrases with tables

If you want a table in your SmartPhrase, the easiest way to include it would be to make
your template in Microsoft Word, and copy and paste it over into an Epic SmartPhrase.
All the formatting will show up, more or less intact, when you use the following
as .QGOUT in your SmartPhrase list:

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 Clinical diagnostic rule for gout
Reference Clinical variable Points
Acute onset, with maximal symptoms within 0.5
guide one day
Joint erythema 1.0
SmartTools Hypertension or cardiovascular disease* 1.5
Male patient 2.0
Previous attack of arthritis or joint pain 2.0
First metatarsophalangeal joint is involved 2.5
Serum uric acid > 5.88 mg per dL 3.5
Total score: *** (maximum: 13 points)
Derivation study Validation study†
Total score Number of patients in the LR Number of LR Suggested action
score range (with gout/total) patients in the
score range
(with
gout/total)
≥ 8 points: 197/245 (80%) 3.1 141/162 5.2 Diagnose gout
high risk (87%)
4.5 to 7.5: 17/63 (27%) 0.3 75/162 (46%) 0.7 Perform or refer
intermediate for joint aspiration
risk and polarized
light microscopy
analysis of
crystals
≤ 4 points: 2/72 (2.8%) 0.02 3/66 (4.5%) 0.04 Consider nongout
low risk diagnoses

LR = likelihood ratio.

*—Cardiovascular diseases include angina pectoris, myocardial infarction, heart failure, stroke,
transient ischemic attack, and peripheral vascular disease.

Adapted from Kienhorst LB, Janssens HJ, Fransen J, Janssen M. The validation of a diagnostic
rule for gout without joint fluid analysis: a prospective study. Rheumatology
(Oxford). 2015;54(4):612, with additional information from reference. In Am Fam
Physician. 2016 Sep 15;94(6):505-506.

Note that when you borrow from citable sources it’s polite to include a citation, as
above. Feel free to use tiny print for that part.

SmartPhrases with graphics

You may also wish to copy graphics into a SmartPhrase, which can be accomplished
simply by copying and pasting. Keep in mind these take up room in Epic that can never
be freed up, so share these with other users as much as possible and exercise good
citizenship. Big graphics will make working with your note slow; try to stay away from
anything much bigger than 500 x 500 pixels. I keep a list of pictures of OTC medicines in
my list of SmartPhrases starting with .G (for graphics), like .GCAPSAICIN:

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These come in handy for patients with limited literacy (or just difficulty navigating their
way through the pharmacy shelves). They will print out nicely in your after visit
summaries, and show up intact in the online AVS as well for later reference.

Sharing SmartPhrases
If this sounds interesting but like more work than you care to do, borrow SmartPhrases
from someone else; at Providence, no one can stop you. If you use the Oregon-
California Epic instance, for example, go to your SmartPhrase Manager, under the upper
left Epic menu > Tools > SmartTool Editors > SmartPhrase Manager:

And in place of your own name in the first box, put my name, last name first (or the
name of another Epic nerd):

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SmartTools

You can click the first “Go” box to get a list of all my 1000+ SmartPhrases. If you know
the name of the SmartPhrase you want to look at, put at least the first few letters in the
second box. For example, to get a look at all of my letter SmartPhrases, type L in the
second box, and click the Go button next to it:

That will yield everything beginning with L on my list:

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SmartTools

If you are going to have a long list of SmartPhrases, you should consider a naming
convention so you can make a distinction between different sorts of SmartPhrases,
like .LEAD for a lead level, .LLEAD for a letter about a lead level, and .QLEAD for a
questionnaire about LEAD. I use the following:

Initial letter Meaning

C Consultant information
G Graphic
I Patient information
L Letter
N Note template
P Procedure
R Result (lab result letter building
blocks, like “Your A1c is better;
we’ll recheck in 6 months.”)
X Physical exam element
E (as a second letter) Spanish version
P (as a second letter) Pediatric version

If, in a list of my SmartPhrases, you came upon my Spanish, pediatric dietary guidance
(IPEDIETINFANT and IPEDIETKIDS, where the first three letters mean patient
information, pediatric, español), for example, and wanted it for yourself, you could
select one or more boxes (click on the first box, then Control-click on subsequent ones
or Shift-click to get a range):

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Then click on the green plus sign where it says Share:

You can add your own name (and, in fact, the names of several pals) to add these
SmartPhrases to your list:

If you press “Accept,” you get my actual SmartPhrases on your list. If I make changes in
the future, you’ll see them, but unless I give you owner permissions you cannot edit the
SmartPhrases to suit yourself. If you click the checkbox near “Copy selected
SmartPhrase(s)” instead, you’ll get your own versions, using my original name, which
you can edit to your heart’s content (but you won’t get any of my updates). I, as the

87
 owner of the SmartPhrase, can also click the “Make users SmartPhrase owners” box
Reference which gives the recipients permission to change the SmartPhrase for all of its users.

guide Another way to access Owner and User information is from the editing window of each
individual SmartPhrase:

SmartTools

Switch over from the Content tab to the Owners & Users tab:

SmartPhrase owners can add and remove users on the right. SmartPhrase voyeurs can
add and remove themselves only, most easily by the shortcut buttons on the bottom
right, “Add Myself” and “Remove Myself.”
88
 Leveraging a comprehensive SmartPhrase library
Reference SmartPhrases help repetitive documentation tasks a lot easier. If you find yourself
typing a version of something more than once or twice, such as a specific kind of work
guide excuse letter, physical exam element for anxious folks, or patient instructions for dealing
with ingrown toenails, you have probably come upon a candidate for a SmartPhrase.
SmartTools
For example: if you don’t like the letter templates available to you, you can have a
bunch of your own (or borrow your colleague’s). When I want to send my Spanish Pap
smear result letter for 30+ year olds, I use a blank letter template, then type
“.lepap30snormal” into it. (Actually, I just type “.lepap3” —Epic types the rest.)

When I refer patients to specialists, I use one of the lists we share in our clinic:

“Call for your colonoscopy appointment: .cgi,” and out pops a list of the GI offices we
typically use. (In case you missed the rationale behind the names of my SmartPhrases
with the L’s and C’s, see above.)

Instead of typing out physical exams or clicking a bunch of buttons in NoteWriter, I keep
lists of exams by system and condition, starting with .x, then I chart by exception:

.xpuri (for pediatric cold/cough visits):

Gen NAD, non-toxic

HEENT Conjunctivae clear, PERRL, EOMI. Throat clear, MMM.
TM's clear without erythema or bulging; no otorrhea
No flaring
Neck No lymphadenopathy, NT, supple
CV Regular rhythm, rate unremarkable. +S1 +S2, no
murmur/rub/gallop
Lungs Clear to auscultation bilaterally, no tachypnea, no increased work
of breathing
Abd NT/ND/S
Skin Color unremarkable; warm, dry
Psych Responsive and interactive, appropriate for age

.xlbp, for low back pain:

Gen Well-nourished, appears stated age, no acute distress

Neuro 2/4 quad DTR's

MSK Strength grossly intact upper extremities; normal gait. Tender *** L
> R paralumbar spine; no supraspinous tenderness. Negative
straight leg raise. LE strength 5/5 throughout.

.xpsychdepressed, for the Psychiatric part of the exam for the dysphoric:

Psych Moderately dysphoric, periodically tearful

Casually dressed and groomed, thought processes intact, thought
content as above;
Affect appropriate in content, normal range; not attending to
internal stimuli; judgment intact

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 These are similar, in spirit, to the physical exam SmartBlock macros in NoteWriter, only
Reference you’re going to use “dot phrases” (like .xlbp) instead of macro buttons.

guide Hanging indents

Note that above, I use hanging indentation for my physical exams. No matter how many
details about fashionable clothing or hyperreligiosity I might add to my mental status
SmartTools
exam, the Psych header will remain out there on its own to the left where you can see
it, and the exam stays indented to the right. I know not everyone might be as into this
finery as me, but I don’t mess with it in the exam room: it’s just set up once in the
SmartPhrases, and then pretty much takes care of itself:

Be sure you have the  ruler set to display (check under the Star menu if it isn’t), then
move the  lower (indentation) margin over to, say, 1 inch (where the first tab stop is)
while the upper margin stays over at zero on the left. I also keep the  Decrease left
indent button around for when I accidentally start typing in an already indented
paragraph when I didn’t mean to, to unindent it.

SmartLists
SmartLists (called “dropdowns” by some) are system-defined lists of phrases you can
use in progress notes. They can be “single select,” where you are only permitted to
choose one of the several options they present, or “multiple select,” where you can
choose one or more.

Some SmartLists, when you select a response, store data in Epic that we later use for
reporting. They show up in note templates as text surrounded by (or “delimited” by)
curly braces. You can’t tell if a SmartList stores reportable data just by looking at it, but
sometimes the first part has hints:

Alcohol abuse screen {PQRI MEASURE 173 - ALCOHOL SCREEN WAS

PERFORMED:23960::"was performed"}

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 One navigates to a SmartList using F2 to select the next one after your cursor, and the
Reference other following options:

guide Key Meaning

F2 Select the next SmartList after the cursor (or *** wildcard)
Shift-F2 Select the previous SmartList or wildcard. Note that sometimes
SmartTools
Windows will intercept your Shift-F2 and figure that you meant
expand the window your Epic session is in. Shift-F2 again will set it
back, usually. Or, you can just keep pressing F2; once it gets to the
last SmartList in your document it will wrap around to the top again.
 (down Move to the next phrase in a SmartList (or left click over it with the
arrow key) mouse)
 (up arrow Move to the previous phrase in a SmartList (or left click)
key)
Enter key Complete selection(s) and move to the next SmartList or wildcard (or
right click)
Spacebar Select the highlighted item
Esc (escape Escape out of the SmartList without selecting anything
key)
Left click Select the highlighted entry
(with mouse)
Right click Exit the SmartList, selecting the previously highlighted (such as left-
clicked) entries
Double click Select the highlighted entry and exit the SmartList
(with the left
mouse
button)

The “syntax” of a SmartList is:

{ display text:ID number:c:default item, another default item:d }

The “display text” can be anything, but it usually the name or description of the
SmartList so end users can see what they’re selecting.

The ID number is the actual identifier of the SmartList in Epic’s internal database.
Executive summary: don’t change it unless you want another SmartList.

SmartList connection logic

The “c” stands for connection logic: n = Nor, o = Or, a = And, p = Paragraph, x = None, s
= Sentence. If you use “a” for example, in a multiple-select SmartList (where the user
can select more than one choice), and they select “red,” “blue” and “green,” the output
will be “red, blue and green” (emphasis added). End users can override whatever
connection logic was originally defined by adding a letter here. In a single-select
SmartList, the user can choose only one answer (e.g., one of red, blue or green) and
connection logic doesn’t apply. Whether a SmartList is multiple or single select is
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 defined at the system level, and can’t be changed by the end user. But, end users can
Reference change the connection logic by putting in one of the letters above after the second
colon.
guide
The default answers in a SmartList are choices that are pre-selected for the end user:

SmartTools

In the example, once the user types F2 in front of this SmartList, Epic hovers over
“Retired” as an answer. End users can change the defaults by filling in their own after
the third colon (capitalization matters here, so define these with care to avoid unsightly
duplicates).

The “d” parameter (after the fourth colon), if set to 1, will use the first parameter—the
display text— as a label, meaning “when this list is used, add the label to the text.” From
Epic’s own “Notecraft—Note Templates for Super Users”:

Yields this:

But if you delete the SmartList, nothing shows up. This is available in Epic 2015 onward.
This comes in handy with the next feature.

Available in Epic 2015 onward is the “optional SmartList.” Optional SmartLists are set up
at the system level. If they are marked as optional, you don’t need to use the SmartList
to sign the note. If it isn’t selected, it’ll just disappear. This can be used to put
instructions in your note that disappear when it gets signed, such as:

{ Provider instructions:30999::Be sure to documentation tobacco cessation

efforts when using CPT 99406 3-10 min, 99407 > 10 min for counseling }

(That’s just an example and doesn’t actually work.) Note that end users can’t define
their own SmartLists in Epic until Epic 2018 (unless the user has a security point to edit
SmartLists, but then there’s nothing to prevent them from editing any SmartList). You
can sort of fake a custom SmartList by using the Blank single (19197) or Blank multiple
(19196) SmartLists then using the defaults to put in your own answers:
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 {Eye color:19197::”Red”,”Yellow”,”Blue”,”Green”,”Completely Black”}
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SmartTools

You’ll always get a wildcard (“***”) on top, and the last option will always be defaulted.
(If you use 19197, all the options will be selected and end up in your note unless you
deselect them.) If you can put up with that, go right ahead. Epic says the original
purpose of 19196 and 19197 was to have blank SmartLists, though I’m not sure why
you’d want to.

Creating your own SmartLists

Epic 2018 introduces personal SmartLists. They work the same as the original ones,
except end-users don’t have the option of having SmartData-enabled selections. (If you
don’t know what I’m talking about, that’s okay for now.) Users can use the SmartLists
activity to create and share their own SmartLists without accidentally damaging system
lists. This involves a two-part workflow:

Epic 2018 SmartList activity

Start with the SmartList activity (Epic menu > Tools > SmartTool Editors > SmartList).
This will let you open up an existing SmartList (including your own, another user’s, or a
system list that you can save an edit as your own), or, in the second pane, make a new
one.

Once you’ve selected (or elected to create) a SmartList, you’ll end up in the SmartList
Editor, which may look something like the controls of a jumbo jet:

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 Your SmartList deserves a name in the system. (You probably already selected it from
the SmartList activity above.) Give it a unique one, perhaps prepended with your initials,
so others looking in the SmartList library don’t have to figure out the differences
between a half dozen different versions of “Psych exam.”  You’ll also get to select a
number. If you use the ‘automatic’ option you’ll get the next one available, which is
probably fine for end users. The number (not the name) is how you’ll refer to the
SmartList in your note templates, e.g., { :20034 }.

 The “Display text” of a SmartList shows up if you select Yes (instead of blank or No) in
the Label field, . In this example, we’d get:

PSYCH EXAM: alert,oriented, in NAD with a full range of affect, normal behavior
and no psychotic features

Also available here are tabs to describe users (people who have access to) and owners
(with an extra “Can Edit?” checkmark, people who both have access to and can modify)
this SmartList. In the Used By tab you can see what SmartLists, SmartTexts and
SmartPhrases currently use this SmartList. So if a lot of people are sharing yours, you
might think twice before messing with it.

 The big area here contains the distinct selections available in your SmartList. With the
options above, you’d get the following:

Note that selections can be plain text, another SmartList (like the psych exam negatives
and positives shown), a SmartLink (say, the patient’s weight or the current date), or a
SmartText (such as note template or a set of patient instructions).
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  In the Selection Type box, you’ll decide between a Single Select list where only one of
Reference the options in  is available (like Yes/No/Sometimes), or a multiple select list where you
can select 1 or more (as in the example above).
guide
 The connection logic is the way multiple selections in a SmartList get linked together,
as described above.
SmartTools
 If you select “Yes” here, you’ll get an optional SmartList. Traditionally, you wouldn’t
be able to sign a note until all the SmartLists were resolve, but if you get this to “Yes”
the SmartList will simply disappear if no item is selected. That’s a good way to leave
behind instructions, like { If PHQ-9 > 12, consider a psych referral :23400 }. Selected Yes
here will add “(Optional)” to your Display text ().

You can also select Mutually exclusive groups here using the group key column ().
Let’s say you had a normal line in your psych exam, and you never wanted users to be
able to select that along with abnormal items:

In this example, if you had the first normal line selected, and then tried to select in
addition (with a multiple selection SmartList, as described in  above):

Selecting either the second, third or fifth item would automatically deselect the first
one, and vice versa, since you can’t be both normal and abnormal at the same time. (At
least in this SmartList.) Pertinent negatives don’t need a group key, though, as they’ll get
along fine either with the normal members of group 1 and the abnormals in group 2.

The Refreshable item here will let people re-right click on this SmartList to reselect its
selections. You’ll usually want this on, in my experience.

 If you want one of the selections in the selection list () to be another SmartList,
insert it here. That’s how the {Psych exam negatives:22683} ended up in there. OK, you
could just type it in braces, but by using the Insert button here you can search through a
list instead of memorizing the ID number of your target SmartList, and fill in the
arguments of connection logic and labels. The Add to SmartList button will put your
selection into the selection list () above, and the Copy to Clipboard button will stick it
on the clipboard instead, where you can paste it somewhere else.
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 If you want to put in a SmartLink as one of the selection options, use the Insert
Reference SmartLink tab. You can select filters, which will make the selection visible only if you are
(for example) in a Letter or Patient Instructions. You normally don’t want to use filters,
guide probably. Epic will use the syntax {:LNK,TD} where :LNK means it’s a Smartlink and DATE
is the mnemonic name of the SmartLink. Once you add a SmartLink, Epic will make your
SmartTools SmartList non-refreshable, I think to prevent conditions where your note may re-write
itself if it gets refreshed.

Finally, if you use the Insert SmartText tab, Epic will let you refer to any available
SmartText (and its filters, similar to the ones for SmartLinks, above), and add it in the
selection list as something like {ADDRESS LABEL:TXT,10600}. Note that you can come
items on one line, like {:LNK, TD} {:TXT,10600}.

 If the “Released” box isn’t clicked, you can’t actually use the SmartLink (but can work
on it). In other words, click this box. Use Save As to save the Smartlist on the screen with
a new name (which you’ll want to do when saving a system SmartList you’re modifying),
and otherwise use Save to save revisions to a SmartList you’re working on.

SmartLinks
SmartLinks pull information out of Epic into your note, like @td@ for today’s date and
@now@ for the current time. You can access them in a progress notes just like a
SmartPhrase, by typing something like “.DIAG” (which gives you a list of current Visit
diagnoses). You can also put them inside a SmartPhrase by delimiting the “mnemonic”
name of the SmartLink with @ signs, like “@DIAG@” (capitalization doesn’t matter). A
big list of potentially Useful SmartLinks is in the Appendix.

https://xkcd.com/1706/

A note on SmartLink notation

• As above, you can type a SmartLink by prefacing it with a ‘.’—like .diag, which brings
in the list of visit diagnoses into a progress note
• You can reference a SmartLink by delimiting it in @ signs, so if you want a
SmartPhrase that has a SOAP note template with .diag in it, you would enter it as
@diag@. (You could also type .diag in the SmartPhrase manager; Epic will transform
it before your eyes into @diag@.)
• SmartLinks, like the lab SmartLinks below, take arguments or parameters (derived
from the same nomenclature you used learning about functions in high school
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 math), like .lastlab[hba1c:3, which can also be expressed as .lastlab(hba1c:3). This
Reference means the last 3 hemoglobin A1c results. You can’t mix this notation. Either
surround SmartLink arguments with left and right parentheses, or use a left square
guide bracket (without any closing right square bracket). Not all SmartLinks take
arguments; to figure out what sort of arguments they take, type the name of the
SmartTools SmartLink without an argument, and you’ll (often) get some explanatory text, such
as for @lablast@:

Lab SmartLinks
Epic includes several kinds of lab result SmartLinks, each with its modestly distinct style
of output. Most take several parameters: a comma-separated list of lab “basenames”
followed by an optional number of results to show. From “Notecraft—Note Templates
for SuperUsers,” here are some examples:

@labrcnt(glucose:3)@ (intended for inpatient; typically limited to the last few days)

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 @last24hourslabs@ (no arguments, intended for inpatient)

Reference
guide

SmartTools @labrsltline(glucose:3)@

@brieflab(glucose:3)@— brieflab does not show reference ranges

@lastlab(glucose:3)@ — includes reference ranges

@lastlab(chol:2,hdl:2,ldl:2,trig:2)

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@resufast(chol:2,hdl:2,ldl:2,trig:2) — no separate headers for components, no reference ranges

Finding lab basenames

So how do you find those lab basenames to use in lab SmartLinks? Take a look at the
result report for a given lab in Chart Review > Labs:

Scroll down to the bottom of the report:

Click on the text (highlighted in yellow above) that says “Lipid panel,” below “View
SmartLink Info”:

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Above, you get a link of the Base Names (in the third column) that you can use to make
a SmartPhrase to return the lab values you’re interested in.

For example, here’s my SmartPhrase DMLABS, which returns the last 2 A1c’s, and the
most recent LDL and microalbumin:

You might well ask why there’s two different basenames for A1c and 4 for LDL; that’s
because they may (rarely) change over time, and I account for both calculated and
direct LDL’s. With the BRIEFLAB SmartLink, results that don’t exist in a list like this don’t
get displayed (instead of saying something like “LDLCALC: No results”).

RESULTRCNT SmartLink
If you want all of the recent labs without specifying basenames, you can use the
RESULTRCNT SmartLink with a time argument. It accepts a number, then ‘h’ for hours
and ‘w’ for weeks. I have the following SmartPhrases, for example:

SmartPhrase name Contents Returns

LASTLAB6W @resultrcnt(6w)@ Lab results from the last six 6 weeks
LASTLAB12M @resultrcnt(52w)@ Lab results from the last 12 months
LASTLAB6M @resultrcnt(26w)@ Lab results from the last 6 months

Output looks like this:

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A similar SmartLink, @LastlabG@, will take arguments of a number, then ‘d’ for days,
‘w’ for weeks, ‘m’ for months and ‘y’ for years, and an optional second number (1 hides
comments, 2 hides comments, ranges, and status). For example, .lastlab[6m,2 yields:

LASTPROC SmartLink
What if you want to get at something that doesn’t have a basename, like an EKG or
echocardiogram? You can use the @LASTPROC@ SmartLink, which can get at results
based on their “procedure” number. You can see these in the result report in Chart
Review, in brackets:

So, for a “complete echocardiogram,” you’re looking for ECH114. (Note that other
varieties of studies, like an exercise echocardiogram or TEE will have different procedure
numbers.) In this example, you could make a LASTECHO SmartPhrase with the contents
@LASTPROC(ECH114)@, which would yield this:

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 LASTIMG SmartLink
Reference Another SmartLink, @LASTIMG@, retrieves imaging studies, and if you feed it ECH114
you’ll get a more detailed report:
guide

SmartTools

I’ve used LASTIMG to make a SmartPhrase LASTMAMMO, but owing to the varieties of
screening mammograms used (with tomosynthesis, digital, etc.) one has to include
several different versions to make this work:

And as the studies change, these numbers may change over time too.

N.B.: This doesn’t work for everything. For labs using a Cerner interface, including much
of Providence for example, there’s no way to make a LASTPAP SmartPhrase.

Flowsheet SmartLinks
Some handy information isn’t available (yet) via SmartLinks, but is stuck in the
Documentation flowsheets—the same place you put everything from Vital signs to
answers to the PHQ-9. Much of the time, we’ve built system SmartPhrases for you that
bring in the most commonly used flowsheet values you’d want in your note, like various
clinical questionnaires:

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The @CLFLOW@ SmartLink will return the last value of a given flowsheet row (where a
row might be something like the answer to the first question in the PHQ-9), along with a
timestamp. The similar @FLOW@ SmartLink does the same thing, just without the
timestamp. These SmartLinks take parameters: the flowsheet row ID (like 2100100050
for the answer to the first PHQ-9 question), and then LAST or FIRST to get the LAST or
FIRST value in the encounter. It won’t let you get the last 3 (for example) values, and it
can’t get rows from previous encounters, on ongoing frustration of Ambulatory users
who would like to put in the last occurrence of a diabetic foot exam or retinal exam in
their progress note (unless you entered that information during the current
encounter).23

What if you wanted to make your own SmartPhrase, though, that brought in flowsheet
values? How do you figure out what the row ID numbers are?

Head to the Flowsheet activity (More Activities > Flowsheets), and find the flowsheet
you want to examine.

23
It is possible, at the system level, to reference a Doc flowsheet with a Review flowsheet, which
has SmartLinks that will retrieve data across encounters. Or you can use the @LASTFLOW@
SmartLink, but it only works for values in the last year and only displays the very last value. Most
of the time when I need to get flowsheet data across encounters, I use an Epic-built, specific
SmartLink like LASTBP and LASTWT (see below).
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If needed, show the row information pane by clicking on the expansion arrow,
highlighted in yellow above:

Then got to Epic Menu > Help > Help Desk Reports, and click on the “REPORT & PRINT
GROUP ASSISTANT” link:

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Then, head back to the Flowsheet activity, and click on the box where you would enter
the information into the flowsheet (like “Temperature” or “Foot Exam-Sensation”):

The Row ID should show up in the information pane on the right when you scroll down
to the “Debug print group” table, highlighted in yellow above. Above, you can see the
flowsheet row ID for the sensation portion of the diabetic foot exam is 26876, so you
could use .FLOW[26876 (with no closing bracket) to bring in the foot exam result:

One you press space or enter after the number, you get:

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You could then have @clflow(26876)@ to put the diabetic foot exam in your own
SmartPhrase, with a timestamp, but it still won’t get anything outside the current
encounter.

Review flowsheet SmartLinks

Besides the flowsheets referenced above (originally known as “documentation
flowsheets”), originally designed for data entry in the ICU, there are also Review
flowsheets, which are view-only but have the capability of retrieving values outside the
current encounter. This could solve your problem of figuring out when the last diabetic
foot exam was done.

To do that, someone at the system level has to define a Review flowsheet that
references the diabetic (documentation) flowsheet. (I know, that’s confusing.) Review
flowsheets underlie Synopses, so if there is information in a Synopsis you can often get
it into your progress note. The diabetes information happens to be in Review Flowsheet
385, so you can add that to your note by typing .revfs[385 (or better yet, putting
@revfs(385)@ in a SmartPhrase. In fact, this has already been done for you, in the
system SmartPhrase at Providence call “.diabetesdashboard” which also adds relevant
labs and medications:

One way end users can figure out what Review flowsheets are available is by looking at
the Review flowsheet activity under More (Activities):

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The Review flowsheet activity: More (activities) > Review flowsheets

 Select the Review flowsheets activity from More (Activities) > Review flowsheets

 Search for a specific item, or just click on the magnifying glass to bring up the whole
list of available review flowsheets

 The number on the right side can be fed to the RevFS SmartLink, e.g., to get a list of
Epworth scores, @revfs(382)@. You can make that the last 3 scores, if you like, by using
@revfs(382:3)@; without the number it will default to the last 7 scores. You can’t leave
out rows in the review flowsheet, but you can put in multiple review flowsheets if you
like, as in @revfs(382,27004:3)@.

Sundry useful SmartLinks

It’s common (if uncouth) to stick the whole medication list in a progress note, but much
of the time, for follow-up appointments, this bloats the note without providing much
illumination. You can use SmartLinks beginning with “.meds” (like “.medsantidiabetics”)
to list medications from certain pharmaceutical classes. See the SmartLink listing in the
Appendix for a detailed list.

I find it useful to use trending SmartLinks in my progress notes, listing the last 4 blood
pressures or weights. Many of them are inconvenient to type, so I make SmartPhrase
abbreviations that in turn refer to the SmartLinks (and their parameters).

SmartPhrase Content of SmartPhrase: What it displays

name SmartLink

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 BP @lastbp(4)@ Last four blood pressures
Reference WT @lastwt(4)@ Last four weights
HCT @brieflab(hct:3)@ Last four hematocrits
guide A1C @brieflab(hba1c:3,hba1cex:3)@ Last four hemoglobin A1c’s (takes
into account external results)
In basket FU @afutappt@ Upcoming appointments

http://xkcd.com/1447/

In basket
Organizing the In basket
You have probably noticed that items in your In basket are in some kind of order, and
unread items are boldfaced. You have control over all this, either by clicking on the
column headings to determine sorting priority (first by date, then by unread status, for
example) or using the “Sort & Filter” menu that’s been hiding there in plain sight:

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The Advanced Sorting option is probably the easiest way to set things up in a way that
makes sense to you:

You may just want results in chronological order (but can choose ascending or
descending). Decide if you prefer the date they were ordered (“Visit date”), the date
they were resulted (“Result date”), or, less likely, the date someone forwarded the
results to you (“Sent date”).

You can use the wrench at the top of the In basket to customize the list:

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You can use the Edit Column Setup option to re-arrange the columns (maybe you want
to hide the ordering provider, and Resulted status, like Final or Preliminary):

The simpler you make the display, the easier it may be to look at. In Epic 2017, you can
use the “Configure Buttons” option to shift over less often used buttons. For example,
perhaps you never care to look at the Result Flowsheet, so you can shift it over to the
“Other Actions” menu by moving it far to the bottom of the list with the “Move Down”
button above.

http://xkcd.com/1478/

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 Dealing with results
Reference Epic offers you plenty of options dealing with results.

guide Done vs Reviewed

People can use Epic for years without understanding the fine distinction between
marking a message marked “Done” and “Reviewed” (for Results, or “Complete” for
In basket
encounters) except to know that you only have the option of doing one or the other
(since one of the buttons is nearly always grayed out). Either way, after clicking the
button that’s working at the time, the message goes away so you don’t have to look at it
anymore.

Warning: don’t read the following paragraph if your head is already on the verge of
exploding.

The distinction being made is that “Reviewed” means you looked at an item that has
“responsibility” enabled—usually messages sent to a pool of people who each have
responsibility. Messages with responsibility enabled have green ball icons next to them,
and are typically sent to a group of people (like a pool) who are collectively responsible
for them. If there’s no green ball icon, you’ll only be able to press Done, meaning you
reviewed the results and took any appropriate follow-up action. If there’s a green ball
icon, you’ll press Reviewed instead, which removes the messages from the in basket of
everyone in the pool and marks it as, umm, Done.

Result Release
You can attach “MyChart patient result comments” to notes, visible both in Chart
Review and to the patient in MyChart. Enter and edit Patient result comments in the
Results Release activity.

Result release activity in Epic 2017 results toolbar

Result release activity of man standing by two glowing test tubes in Epic 2014

While you can write a whole plan to the patient here, it’s designed for short notes about
the results to help clarify the interpretation and plan. I have previously compared the
MyChart Results Release activity to the controls of a jumbo jet, but it’s grown on me
since.

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MyChart Results Release activity

 Select the results you’re going to apply comments to (available if there was more
than one result in the In basket message).

 Type the comments you want to apply to the results, so that patients can see them in
MyChart (and you can see them in Chart Review).

 Use these buttons (or individual check boxes just below) to select which out of the list
of results you are going to release.

 You can review previous comments about each result you’ve made here; you’ll also
note when the results were released, by whom, and whether the patient read them.

 If you want to send a more detailed MyChart message to the patient, press the
“Patient message” button. You can use the Order Entry button (changes to Place Orders
in Epic 2018) to open up an Orders Only encounter and start ordering stuff.

 When you’re done, press the Accept button. If you also want to add a Result note
(similar to the Patient Result Comments you entered on the right, but not typically
visible to patients) click on the “Accept and Open Result Note” button. Result notes can
also be copied to other users, including support staff. See below for details on that
activity.

Result notes are similar to MyChart result comments, but are typically only visible inside
Epic, in Chart Review, and not visible to the patient in MyChart. You might use these, for
example, to remind yourself about an abnormal Pap smear result, putting in a summary
of prior abnormalities and what the follow-up plan is.

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Result note activity

 Result notes that are visible in Chart Review (but not typically visible to the patient)
go in this lower left box.

 MyChart result comments, visible both in Chart Review and by the patient, go in this
lower right box. If you click the “File as QuickNote” box, your results won’t just be
attached to the Lab result report (in the Labs, Micro/Path or Imaging tab in Chart
Review), but also show up as a small Progress note under the Notes tab.

 If you previously put in result comments, they are available via the blue “Previous
comments” link. You cannot edit them (the patient already saw them, after all).

 You can route result notes to colleagues or support staff.

 Under the wrench, you can specify default Result note recipients, or set up a
SmartText to use as a default Result note template. You can precheck other boxes in the
activity too.

 You can select all of the results by default, or just abnormals or individual results here
to attach Result notes to.

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Patient view of MyChart comments (highlighted for clarity in yellow)

Note that while some clinicians will notify their patients only with MyChart result
comments, they are subtle enough that patients may miss them. Especially for
important results, consider sending a secure patient message instead or in addition to
MyChart result comments.

Patient result comments, as seen from Chart Review, indicating when they were entered and when the
patient read them

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Result note in the In basket

Reflex vs Orders Only

The Reflex button opens up a new Orders only encounter, where you can add on
additional labs based on the results you received. For the most part, you still need to call
the lab so they can ensure specimen stability, and attempt to run your new orders off of
the already received specimen.

Result comments
If you want to leave a result or message around in the In basket for further action, you
might add a Comment to it (which other recipients can see too) to indicate the plan of
action. Right click and select Comment; what you type shows up in the message header.
(Highlighting added for clarity.)

Sending a results letter

Epic has two versions of the Communication activity. There is a fancy one (described
above) with the ability to select various templates and multiple recipients, which is what
you’ll use to write your work excuse letters and consultation requests. It looks like this:

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In basket

A simpler one that many organizations use (including Providence) for results letters is
just for sending a note to patients (either by printing it for the postal carrier, or sending
it virtually through MyChart). You get here from the Letter button on the Results
toolbar:

 By default, the letter comes from you and uses a results template. On rare occasions
you might change these.

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  The Reason for letter defaults to Results (and you typically wouldn’t change that). Put
Reference in some comments to help find your thread of thought later on, if needed, while looking
in Chart Review > Letters. For example, “Improved cholesterol,” or “A1c way up.”
guide
 You’ll typically route letters to your support staff pool by pressing the Add My List
button. (Because earlier, you put them in as the default recipient using the Build My
In basket
Lists button, didn’t you?)

 Styles vary; I usually add in some details about the specific results, though I have a lot
of these stored in SmartPhrases for results, like .RA1CGOODCONTROL
or .RA1CNEEDSWORK. (Here, ‘r’ prepends my results SmartPhrases.)

 If you route to a pool, the lower left button changes from “Accept” to “Accept and
Route.” Accept means you’re ok with the letter, and it gets routed off to your staff to
print and put in an envelope. You can also save the letter for later and close the activity,
but getting back to it is not fun. (Joining the Letters encounter from Chart Review >
Encounters doesn’t work; you need to get back to the In Basket, select the result, click
the Letter button again, potentially reselect the results to include, click the View Letters
button on the dialog box, then use the “Accept” instead of “New” button on the ensuing
window. I don’t recommend it.)

Note that, as of Epic 2018, Letters are visible to patients in the web version of MyChart,
but not MyChart mobile (the app that runs on their smartphone).

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 Postponing messages
Reference If you have a message or result you’re not ready to dispense of because it needs further
action at some point, but you don’t want it hanging around where you can see it for the
guide time being, you can postpone it to a later date. When that date arrives, the message
pops up again in your In basket for further action. This is a bit different than setting a
In basket due date for a message, where it will hang around, then turn red on the due date. You
can Postpone messages with the right click context menu (shown over to the left). The
Postpone icon is a clock with an arrow pointing toward it (an envelope with a clock on it
in Epic 2014). You have some preset dates, or you can use the “Choose date” option, as
well as the Postpone button in the toolbar.

See below, at In basket Search, to get a list of Postponed messages (albeit without their
postponed to dates).

In basket QuickActions
The In basket lets you save certain kinds of frequently used responses as QuickActions,
available from the Manage QuickActions menu:

• Result notes are notes attached to results that can routed and see in Chart
Review > Labs and Chart Review > Micro/Path but not typically by the patient in
MyChart. You might have a, say, a collection of abnormal Pap Result note Quick
Actions like “Plan colposcopy,” “Re-Pap 6 months” and “Re-Pap 1 year.” (I don’t;
I feel the need to carefully review the whole Pap history in the patient’s chart
before making such a decision.)
• Letter QuickActions can use existing system-wide templates, so you could have
an Abnormal Result Letter QuickAction which uses the “GEN TO PATIENT,
GENERAL RESULT ABNORMAL” letter template:

• QuickNote QuickActions would let you put a pre-made progress note in the
chart. You might have one for “Needs appt” or “Call again if contractions
worsen.” These can be used for Patient Call In Basket messages, or Rx
Responses or Requests.

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 The button name will show up in the QuickAction dropdown menu.

 The contents of the canned progress note go here.

 You can route these notes to one of a variety of recipient In Basket folders: Patient
Calls, Chart co-sign requests, Rx Request or Response, CC’d charts, among others.

 You can pre-set recipients. “My List Recipients” would be like pressing the “Add My
List” button. (You can also press Add My list here, but if you change what’s on your list
that wouldn’t change the QuickAction recipients later.)

 Show note before filing gives you a chance to edit it before sending; Mark… as
complete gets the note out of your In Basket when you send it.

• SecurePatient QuickActions let you pre-record responses to patient MyChart

messages, like “Sounds complicated. Please set up an appointment with me.”
On the second tab Tasks & Options (Epic 2017 and later), you can pre-assign
questionnaires from the ones in the system, and appointment templates:

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You’ll need to use the Use for: button to set up applicable Messages Types, like Pt Rx
Request or Pt Advice Request, or you can just check “All available types.” Then, when
the message comes in, use the QuickAction dropdown menu:

Which gets you:

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The patient receives this:

And if they take the bait and click on the task, they can choose an appointment:

• Send Message QuickActions are my favorite. They work not just from the In
Basket, but from the More (Activities) menu in a patient chart. See the details in
the Strategy Guide.

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 • Rx Request Approve / Refuse QuickActions let you add a canned progress note
Reference to the chart while approving or denying an Rx Request In Basket message where
a patient is requesting a prescription order.
guide

In basket

In this example, we ok a single fill with an additional refill, put in progress notes
that then get routed to whoever is in my “Build My List” recipient list, and put in
a hint to the receiving staff about how insistent I’m feeling. The Refuse version
works the same, only no fills will be approved and your contents will probably
be a bit more heavy-handed, like “Tell them I’m sorry but they need an
appointment with me first prior to ordering this medicine.”

Attach in baskets
There’s a bunch of reasons you might want to peek at someone else’s In basket:

• You’re covering them while they’re out of the office (or they’ve left medicine to
become a professional cat trainer);
• You suspect a patient sent a MyChart message to you, and because you like to
work ahead, you want to grab it out of your MA’s In basket before he has a
chance to triage it to you.
• You’re a medical director, and you want to see if you need to get on someone’s
case about not getting their charts completed on time.

To embark on this adventure, you’ll click on the Attach button in the In basket toolbar:

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That will yield the following dialog box:

In basket

 In the General tab, enter the names of colleagues whose In baskets you may want to
peak at from time to time. On the upper pane, you can leave a bunch of names around.
Check the boxes on the right at  to actually have their In baskets be visible.

 The lower pane is where you can add names of colleagues whose In baskets you want
to see only temporarily. Names are cleared out of here when you log out. (Unless that
person designated you as their Out of office delegate, in which case their name shows
up here and you can’t get rid of it until they release you.)

 In our institution, everyone has access to everyone else’s In basket. If yours doesn’t,
you go to the second tab here, and put in names of people you intend to grant access
to.

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 To view attached In baskets, you’ll use the “Attached In Baskets” button that will show
Reference up in the lower left of your own In Basket. You’ll then get a list of folders of the folks
whose In baskets you are sharing (viz. left).
guide
Out of office assistant
The Out of office assistant lets you set up one or more occasions in the future where
In basket
you won’t be available to handle your In basket, like vacation, CME, or getting sent to
the joint. It’s available from the In basket toolbar:

The system can be set up to look at only your own Out of Contact occasions, or
everyone’s (in which case you have the opportunity to carefully edit those of your
colleagues):

Usually, you’ll press the New button on the lower left to make a new occasion for
yourself:

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In basket

 Put in a reason to give people an idea of what you’re up to. (“On medical leave,” “In
Namibia searching for drought-tolerant shrubs,” “On a 5 day trip to the Mall of
America.”)

 You’ll need to put in Start and End dates, and optionally times.

 You must delegate one or more covering providers (or coverage groups, if available in
your installation). When a message gets sent to your In Basket, it still gets there, but the
sender will get the following pop up:

The delegated providers will get an “OOC Notification” message in their In Basket to
alert them there is an incoming message for someone they are covering for:

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In basket

They can then go to the Attached In Basket to handle the work. If they complete the
work (by signing/closing an encounter, for example) the system may be set up to deliver
a “Covered work” message to the vacationing provider to let them know the message
was handled, which they might not otherwise see.

Delegates don’t have to attach the vacationing providers In Basket: once the occasion
rolls around on the calendar, Epic will set up the attached In basket for them (and they
can’t get rid of it until the occasion has passed):

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In basket

http://xkcd.com/1729/

Sent Messages In basket

“Sent Messages,” accessible in the lower left of the In basket known as “My Out Basket”
in Epic 2014 and earlier) lets you get at secure patient messages (sent via MyChart),
staff messages sent to others, letters and referral messages. You can’t edit the letters
(as soon as you “Send” them Epic assumes you dropped them into a mailbox, and
messing with the mail is, after all, a federal crime24). You can use the Recall Msg button
to un-send secure patient (MyChart) messages, or Letters sent via MyChart to patients,
or Staff messages, so long as they haven’t read the message yet. Unread staff messages
can edited and resent from here too.

Completed Work
The Completed Work In basket is really a shortcut to a saved chart search. It contains
messages you have marked as complete (by default, in the last 30 days). This is where
you go if you got overly enthusiastic marking messages as Done. Head in here, find what
you’re looking for, and right click on something to move it back to the In Basket, or use
the usual tools to generate phone encounters or release results here.

In basket message search

Above, you read about the Completed Work In basket, which is really a search through
your In basket of messages you’ve marked “Done” in the last 30 days. You can search for
messages about certain patients, or all your Postponed messages, and save searched for
future use.

24
18 U.S. Code § 1708, “Whoever steals, takes or abstracts… from or out of any mail, post office,
or station thereof... shall be fined under this title or imprisoned not more than five years, or
both.”

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In basket

For example, if you wanted a saved chart search for Postponed messages, go to the In
basket toolbar > Search, select “My in basket” (you can also selected attached in baskets
here, if you have any), of “All” messages types, with the status “Postpone” and “all
recipients” and “all priorities.” On the bottom, for “Date Message Received” click on the
“include future dates” box, “No limit, including future dates.” When you look in the
search results, everything you’ve got coming to you should show up. Interestingly (ok, I
think it’s interesting), as of Epic 2017, trying to figure out when a message was
postponed to is challenging. Using the Properties menu (available via right click and
from the toolbar) on the Postpone tab doesn’t show you when the message was
postponed to, but rather resets the date.

Secure patient messages

Patients can send in questions from MyChart as “Patient Advice Requests”:

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In basket

From the patient’s perspective, sending in an advice request from the web version of MyChart

The request will typically land in the Patient Advice Request folders of members of your
support pool:

They can either handle the message themselves, or forward it on to you.

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In basket

When you read a Patient advice request in your In basket, you have options about how
to respond:

 Click on the Reply to Patient button to respond directly to the patient with a
message.

 You can use the “MyChart Enc” button to reply to the patient from inside an
encounter, which also allows you to order labs, and write progress notes (for example,
with instructions to your support staff to schedule an ultrasound). In fact, when you use
the Reply to Patient button above, Epic generates a MyChart Encounter behind the
scenes. You can join this encounter (using the Encounter button) in Chart Review >
Encounters, in case you decide you want to enter some orders or progress notes after
all. Some installations of Epic may contain the similar “E-visit Enc” button which allows
you to enter a level of service to bill for MyChart encounters.

 If you don’t need to further respond to a patient message, you can mark it as Done
(or Complete if it has attached responsibility; see above).

 If responding by MyChart message isn’t sufficient, you can generate a telephone

encounter here, enter the chart in Chart Review, or put in a progress note with the
QuickNote button to the associated MyChart encounter (so you could write a note to
yourself or others that would appear in Chart Review > notes). You can also forward the
message to other users.

Providers have a bunch of options they can use when replying to or sending messages
directly to patients (which you can do from the In Basket, using the Patient Msg button
to start a new conversation thread).

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In basket

 The text of your message to the patient goes in the top part of this box.

 You can change the default subject of the message, which is a pretty good idea, since
it will make it easier to follow the thread of the conversation later while you’re wading
through Chart Review trying to figure out when you decided to stop the metformin and
start methocarbamol instead.

 Click here, and any replies go to your In Basket instead of stopping off first at the In
baskets of your support pool members for triage.

 You can change the date a message gets delivered. You might do that, for example, to
send a message to a patient in 6 weeks (w+6) to ask them how they’re doing on their
tobacco cessation journey. Or if they are replying to each of your messages after 10
minutes with more questions and you need a breather.

 Accept and Send sends the message on its way. If the message you wrote is
particularly timeless, you might save it as a template via Save as QuickAction. In that
case, you might add a salutation like “Hi @fname@” so the template generates
personalized messages when you use it in the future.

 You can attach Questionnaires (about specific topics, like back pain) or History
Questionnaires (requesting patients update their past medical history, family history,
etc.). In Epic 2017, you can also attach appointment templates suggesting an
appointment with a specific provider in a specific time frame.

 You cannot change previous messages in the thread, shown below the “===View-only
below this line===” marker; these are just for reference.

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 Chart Review
Reference Nearly everything that isn’t a staff message is visible in a patient’s Chart Review activity.
Lab and imaging reports are straightforward. A few of the other tabs bear further
guide explanation.

Chart Review Chart Review tab Contents

Encounters A report of everything that occurred in an encounter. A
telephone, encounter, for example, will contain the Reason for
the call, the Call documentation (all of the back and forth notes,
which appear individually in the Notes tab), the list of Contacts
used in the call, and the history of who routed the encounter
and when.
Episodes Will list all of the patient’s episodes of care and their associated
reports. For example, a prenatal episode will show the dating
criteria, OB history, OB labs and OB flowsheet with notes. An
anticoagulation episode will show the current dosing strategy,
and recent flowsheet data.
Notes Individual progress notes are here. Some people find this an
easy way to look at office visits, but a tough way to look at
telephone encounters (for the latter, you’re probably better off
in Encounters).
Procedures Contains any progress notes written in the pre-Epic 2017
procedure navigator, Epic 2017+ Quick Procedure navigator, and
ancillary procedures like EEG’s and colonoscopies (at least
internal ones that were authored in Epic as procedures).
Labs Ordered and completed lab studies show here; if you look far
enough to the right, you’ll also see columns about whether the
labs got released to MyChart, and whether the patient viewed
them.
Cardio Cardiology studies, including EKG’s, echocardiograms,
angiograms, and stress tests. Outside studies may only be visible
in the Media tab
Other studies Includes items like PFT’s, endoscopy; sometimes these will also
appear in the Procedures tab.
Orders Includes ordered and completed labs, imaging, and consult
orders (referrals). You might this this useful for printing out
consult requests.
Medications By default, shows the current medications in alphabetical order,
along with their most recent orders dates. You’re probably
better off using the Medications activity.
Media Scanned or attached documents (like photographs and PDF’s)
can be accessed here. You can modify the descriptions in Media
Manager.

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 Letters Letters you wrote in the Communication activity will be here,
Reference along with the Reason for the letter (so put in a Reason,
otherwise you’ll never find anything).
guide MyChart MyChart messages from and to your patient are here; you may
find them easier to review in the Patient Message Review
Chart Review activity.
Referrals Referrals live here. There’s a link to the referral report you can
print at the bottom, but most of what you’ll see here is the guts
of the referral as it’s being processed. The status column will
show if a referral is Authorized, Pending, or Closed (completed
and seen).
Misc Reports Contains a bunch of reports that also live elsewhere. This tab
may not survive long enough to exist by the time you read this,
but it contains a history of messages routed to outside
providers, a link to the Report and Print Group Assistant (also
available under Epic menu > Help > Help Desk Reports), and
Advanced Care Plan Summary

Joining existing encounters

It’s often handy to join an old encounter:

• Updating a chart prep document when a new result or question comes in;
• Continuing a telephone dialog after the encounter falls out of your In basket,
instead of creating a new telephone encounter;
• If, while you’re replying to a patient MyChart message, you realize you should
order some labs or medications for them.
• If you’re helping other people use Epic, and they have questions about why
something in an encounter looks funny.

Find the encounter in Chart Review > Encounters:

Then press the Encounter button. (Or, Alt-n, following the hint of the underlined letter.)
If the encounter was already closed, you’ll be prompted to addend it. Go ahead. You can
always close out of it and do nothing; no harm done.

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 Routing notes and labs from Chart Review
Reference If you’re a PCP, you can help out other members of the care team by keeping them
apprised of your patients’ progress. If you’re a consultant, I recommend sending a copy
guide of all of your progress notes to the PCP. (Epic is often set up to do this automatically for
most consult notes.) It’s easy enough to type in a few recipients in the Routing section
Chart Review of the Visit navigator if you’re on the same installation of Epic. But for providers outside
your institution, consider using the Chart Review > Route button:

 The Route button is available from most tabs in Chart Review. You can use it in the
Encounters tab, but depending on your institution’s setup there may be a lot of
extraneous information no one wants included. By using the Notes tab, you can send
along just progress notes. Click on the notes/labs/imaging reports you want to send (or
control-click to select several), then press the Route button.

 This “Routing” window pops up when you press the Route button. Similar to writing
letters, select recipients. If you’re keeping track of care teams members in the Care
Teams activity, you can just click the Care Teams button as shown here, and check off
your recipients. For providers who routinely use your instance of Epic, route using the In
basket method, just like you do in the Communications activity. For outside providers, if
they have a fax number shown, Epic will send your document by fax.

 If your document has attachments, you can select which ones to send here. (You’ll
usually leave this alone.)

 Type in a message for the cover page here, and then click Send. Space is limited to a
paragraph or two: no treatises here. If the fax machine is out of paper, the system will
try several more times to send along your document.

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 Chart Review filters
Reference Complex patients that you’ve been taking care of for a while can have a lot of
documents in their chart. Chart search is one simple way to find things, but you have to
guide know the specific text that appears in a document, and it gets messy if the same text is
repeated in a jillion documents in the patient’s chart.
Chart Review
Filters, on the other hand, are good for finding documents of certain types, or by certain
authors. For example, if you want to find the most recent Annual Wellness Visit (or all of
the Annual Wellness Visits), or all of the hospital discharge summaries, you could
probably benefit from a Chart Review filter. For filters you’ll use repeatedly, you can
save them as checkboxes in the Chart Review toolbar.

Some of these filters will be pre-made for you, and you can define others. You can make
different filters for the Encounters tab, Notes, Labs, and so forth. My own Encounter tab
has the following saved filters:

So you can tell that I like to sometimes see just the Office Visits, sometimes just Well
Child Checks, sometimes just my Documentation encounters (where I put in Chart prep
documents and some outside consult summaries). ‘R’ stands for anything where I am
the author (because my last name is Rosenberg).

You can select more than one filter at a time—for example, I could check off “Doc” and
“R” to filter in all of the Documentation encounters for which I am the author. You could
also make a “My docs” filter which did both simultaneously.

To use (and potentially save) a filter, click the Filters button on the upper left.

Once you click the Filters button, you’ll get the following window:

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Chart Review

 Select one or more types of items to filter on in the top left box. In the example, I’m
checking off “Provider,” so I can filter by provider.

 Once you’ve selected a type of filter in , you’ll use the actual list of providers that
occurs in this patient’s chart to select one or more clinicians whose encounters you
want to filter on. (The rest get filtered out.) You can also free text a name like “Smith” in
the “Provider contains…” box above, which will filter in anything like Bill Smith, Corinne
Smith and Liz Smith.

 Click here if you want to save the filter for later use for any chart. You’ll be prompted
to give it a name. The shorter you make the name, the more checkbox filters you can fit
into your toolbar.

 You can optionally set a date range on your filter (retrieve only documents for which
you were the author between 2012 and 2015), and, under the Filter Options tab, you
have additional (rarely used) choices for “Selected only” (to narrow a search down to
already selected encounters), “All filters” (to narrow a search down to look only in the
results of a preliminary search), and “All loaded” (to search all of the loaded records).
(Rarely used in my experience.)

 The current results of your filtering are shown here—with a selected note to the
right.

Media tab
Scanned documents, patient photos, and attached PDF documents (like outside records)
live here. The descriptions are usually set by whoever does scanning in your
organization.
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 Media Manager
Reference The Media Manager (under the Epic menu > Patient care) will let you change the
descriptions of existing scanned documents (in case they weren’t accurate in the first
guide place), scan new documents if you have a scanner (usually done by clinic staff, not
clinicians), and import documents (like PDF’s of outside records). End users don’t
Order review typically do this themselves, but you may have permission to, in which case you should
be careful. If you put in the wrong patient’s information you’re going to have some
explaining to do to HIM so they can fix your mess.

You could use the Import button here to attach PDF’s from an outside organization
(typically, medical records). You will need to wind your way through a folder hierarchy
to get to storage locations you have access to. Mostly, end users could make use of the
Edit button here to change the description of a document if you need to improve on its
accuracy.

Order review
You can get to the Order Review activity from the “Review open orders” link in Meds &
Orders in the Visit navigator, Order Entry (the “Open Orders” button on top) and from
the More (Activities) menu.

 Select an order and click the Discontinue button to cancel an order. (Sometimes, like
with immunizations, you can’t do this except from the originating encounter.)

 You can release future or manual release standing orders with the Release button.

 Use the Extend button to change the Expected and Expiration dates of orders. For
many installations of Epic (including Providence labs using Cerner), you should only do
this on orders risking expiration, not ones that have already expired.

 You can get details of orders and reprint requisitions from the details pane; click on
the link, then right click to print.

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 It’s also possible (at a system level) to configure Order review to allow changing the
Reference resulting agency of a lab order or to change the order class, like clinic or lab collect (see
Nova Note 48079).
guide
Visit navigator
Visit navigator The Visit navigator is the activity you’re in when you’re seeing a patient: it’s divided into
navigator sections, like the ones where you’re variously putting in vital signs, a progress
note, and levels of service. The sections available vary according to the type of visit
(scheduled regular office visits will have one sort of visit navigator; OB initial visits and
follow-up visits each have their own layout, as do procedure visits). The navigator may
also look different depending on the department you’re signed into (specialists may
have specific navigator sections, PCP’s others). Some navigator sections may only show
up for certain patients, like “DM Documentation” for patients with diabetes mellitus on
their problem list.

Visit navigator speed buttons

Certain navigator sections have speed buttons that you can configure.

Chief complaint speed buttons

 To set up Chief complaint speed buttons, click on this wrench.

 Once you click on the wrench at , this box pops up. You can type in a list of Chief
complaints (and optional captions next to them), and use the buttons at  to rearrange
the buttons or alphabetize them.

 Once your chief complaint buttons are set up, you can click to select one or more
(and click again to deselect them).

Progress note speed buttons

When you use this activity, you can make a set of speed buttons you can use to bring up
different note templates in one click. You can make distinct collections of buttons for

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 regular outpatient progress notes, H&P’s, and inpatient Discharge summaries and
Reference progress notes.

guide

Visit navigator

You can see from the length of the following list that making progress note speed
buttons is somewhat sophisticated:

 Click this wrench in the progress note navigator section to bring up the Notes
Personalization box seen here (with all the rest of the numbers in it).

 The list of existing buttons is here (with the current one highlighted) along with a
green plus sign (+) to make new progress note speed buttons. Click one of the existing
buttons to edit it, or the + to make a new one. A common error involves skipping this
step; you’ll replace one of your existing buttons with a new one.

 These arrow buttons control which of the existing speed buttons in  you are
editing.

 The caption for your speed button goes here. The shorter you make it, the more you
can fit in the Progress notes navigator section.

 Your speed button can bring up your own SmartPhrase, or a system SmartPhrase.
Alternatively, you can use a system SmartText. At Providence, system-vetted SmartText
note templates are stored under PHS, like PHSAPSO, PHSCONSULT, and
PHSDCSUMMARY.

 Pressing the Delete button destroys the currently selected progress note speed
button.

 Epic 2017 lets you share progress notes with patients in MyChart, as part of the
OpenNotes collaborative. The default state is to share your notes (but this may vary
among departments). You can change that default here.

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 Visit diagnoses speed buttons
Reference There are three sorts of visit diagnosis speed buttons available (but the ones you see
may vary by department): “common diagnoses” that you can edit yourself, “previous
guide diagnoses” that have been previously used on this patient, and “problem diagnoses,”
which reflect what’s on the Problem list:
Visit navigator

 Click one of the list-arrow icons to convert one of the groups of visit diagnosis
buttons to a dropdown menu (you can click the last item in the menu to show the
buttons instead);

 Click the wrench to get into the configuration activity for the common diagnosis list,
which works a lot like the Chief complain speed buttons:

 Make a list of common diagnoses here (with optional captions, if you don’t want to
use the default, which is the first part of the diagnosis name).

 You can rearrange or alphabetize the buttons here, then Accept (or Cancel) your
work.

Note that you may not see any buttons if your patient has no previous diagnoses. The
common diagnosis list here is not the same as the one you see in the Preference List
Editor.

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 Levels of service speed buttons
Reference
guide

Visit navigator
Click on the wrench in the upper right of the Level of Service section to configure the
LOS speed buttons:

 You can then click on any of the buttons on the left to bring up the box  at the right.
You can also use the mouse to drag and drop to re-arrange the buttons. In Epic 2017, if
you drop a button between two other buttons, it will rearrange the neighboring buttons
to make room.

 If you make a mess and want to go back to whatever the system defined Levels of
Service buttons are for your department, press the Restore Defaults button. Press
Accept if you like your changes, and Cancel to discard your changes and leave the
buttons in their pre-existing state.

Order entry
Order entry is an older version of Meds & Orders that nonetheless got actively
developed though Epic 2017. It won’t show you current medications like Meds &
Orders, but it does show you current visit diagnoses and Problem list entries you can use
to associate with orders, and even the current Level of service. Unlike the default setup
for Meds & Orders, it also has an Interactions button (even though it doesn’t show you
the current medication list).

Epic recommends Order Entry’s demise in favor of the new Visit taskbar for those
configuring Epic 2018, so if you’re a lover of Order Entry, see this article in Psychology
Today: “If you love something, set it free: get a leash on your anxious attachment
style.”25 The Visit taskbar does everything order entry does, but you don’t have to leave
the Visit navigator, giving you a significant discount on jankiness.

25
The quote itself originates with Richard Bach, the author of the timeless (well, 1970) “Jonathan
Livingston Seagull.” He also notes:

The mark of your ignorance is the depth of your belief in injustice and tragedy. What the
caterpillar calls the end of the world, the Master calls the butterfly.
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Visit navigator

 The row of available buttons may change over time: I’m trying to skate where the
puck is headed so I’m describing what was in the Epic 2017 Development Preview at
press time:
• Pref list puts you in the Browse view of your preferred orders, like clicking on New Order in Meds
& Orders.

• Interactions checks for drug interactions, including items you’ve got tee’d up but haven’t signed
yet. Not available in Meds & Orders (in the typical setup).

• Pharmacy lets you select one or more preferred pharmacies, the same as if you clicked on the
Pharmacy text at the bottom of the window.

• Providers lets you designate the Authorizing providers for medications and procedures, and
designate co-signing providers. You’ll still show up as the Ordering provider, but you can make
someone else responsible for the results.

• Routing refers to where the orders get sent to. For example, if you’re in your office ordering labs,
the orders would usually go to a nearby lab for processing. But if you’re taking a call about a
patient at another hospital, you might want their lab to get the order instead. (This isn’t usually
used at my institution.)

• CC Results lets you add additional recipients to lab/imaging orders. For example, if you’re
ordering a phenytoin level, you might have it sent off upon being resulted to the patient’s
neurologist. This works only for folks on your instance of Epic; for outside, folks, use the Route
button in Chart Review once the result comes back. Not available in Meds & Orders.

• References brings up the activity that looks at your diagnoses and orders and suggests patient
handouts, fulfilling Meaningful Use requirements, if you’re into that. (I find it’s often not useful,
but that may be because I’m narcissistic.)

• Open orders send you to the Order review activity.

• Pend orders lets you complete entering the orders without signing them. You can then log out of
the workstation and revise and sign them later, and/or free up the orders activity for others users
in your patient’s chart at the same time.

• Financial summary brings up your patient’s coverage info, and theoretically can analyze your
orders to tell you how much your patient is in for, though I’ve never seen this fully set up.

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  Put in new orders here, and designate if you want to search both through
Reference medications, procedures (like labs and imaging) or both. You can click on New order
defaults to set up, say, an Expected date and/or Order class (Normal, Manual Fax) (not
guide available in Meds & Orders) or use the Edit Multiple to change these sorts of settings on
queued up orders.
Visit navigator
 The Edit multiple button lets you change attributes of multiple queued up (entered
but not signed) orders, like the Order class (Normal, Print, Manual Fax), Start date and
Refills. Phases of care refers to inpatient orders: some things you want given in the
PACU, others on the post-op floor, or signed and held for later release.

 The Previously Signed Orders link takes you to the Order review activity.

 In the southern portion of Order entry, you can add, remove and edit visit diagnoses,
and use these to associate with your orders. Some people use the Associate All button,
which associates all of the visit diagnoses with all of the tee’d up orders. To this
demonstration of enthusiastic laziness I salute you! Though I suppose you may
potentially be gumming up the works for your billers from time to time. The left and
right arrow buttons let you move items between the Visit diagnoses and Problem list.

Meds & Orders

Customizing columns
The Meds & Orders navigator section has a bunch of tools to help organize your lengthy
medication lists.

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Visit navigator

 The topmost wrench in the upper right opens up the List view selection, seen at.

 The List view selection buttons let you organize your medication list by dividing it into
Medications on top and Procedures you’ve ordered (like labs and imaging) below, by
associated diagnoses, or (as shown) the pharmaceutical class (like Antidiabetics). The
pharmaceutical subclass option divides things further (like sulfonylureas vs insulin). The
Choose Columns link on the right displays the column selector, shown at . If you’re in
a telephone/refill encounter, you can also group meds by whether they were approved,
refused, or ordered outside the encounter.

 The column selectors (changed a bit in Epic 2017) let you hide or display the following
columns. The more you display, the more information and options at your fingertips, but
your med list will look longer and maybe a bit more confusing. I’ve underlined the ones I
find helpful.

• Dose, frequency. That’s the column where it says “1 tablet, Daily.” It only works if you are using
the discrete sig fields.

• Dispense as written. Will show whether or not you specified DAW while you’re looking at the
Meds & Orders med list.

• Patient sig. This is the free text sig you may have entered.

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 • Start corresponds to when you told the patient to start this medication order. It is usually the
same as the Ordered on date, and unless you changed it (which you might do when printed out
Reference multiple controlled substance refills with staggered dates). Start is not the same as the first date
you ever ordered the medicine; whenever you re-order a medicine (what you might think of as
guide ordering more refills) Epic considers that a new start date, and an entirely new order.

• Authorized by will include a column showing the authorizing provider. This is usually the same as
Visit navigator an ordering provider, but if an ancillary staff member (RN, Central Refill) sent in an order on your
behalf, they are the ordering provider and the responsible clinician is the authorizing provider.

• Discontinued on is the date that a medicine was marked as discontinued (for example, by right-
clicking and selecting the discontinued option). The DC reason is the reason the medicine was
discontinued; it’s a good idea to put something in there so you can remember why the patient
isn’t taking the medication anymore.

• Dispense is the amount of medicine (like 30 tabs, or 240 ml) the pharmacist was instructed to
dispense, and refills the number of times the pharmacist has permission to refill the medicine
prior to needing a new order.

• Last dispense (like Ord/sold) refers to when the pharmacy actually dispensed the medicine. It
won’t show anything unless it’s an internal pharmacy running on the current instance of Epic.

• Pharmacy refers to the pharmacy the medication got sent to.

• Prior authorization refers to the prior auth status of a medication that underwent the e-Prior auth
process (I think).

• Dx associated will show an icon that, if you hover over it, displays the diagnoses associated with
the medication when the order was signed.

• Order report link will put in a blue “Report” hyperlink that, when pressed, will pop up a full
medication report, including the sig, ordering and authorizing provider, pharmacy, fills remaining,
and so forth.

• Taking will display a checkbox (for display only in Epic 2014, but workable in Epic 2017) that
reflects whether the patient says they’re taking the medication or not. Typically, staff use this to
record taking/not taking status in their Medication review activity during rooming, and providers
can see the results in Meds & Orders.

• Long-term will display an empty box vs a pushpin for medications marked as long term. Long term
medications don’t fall off the medication list once they reach their end dates.

• Med note refers to a blank page button that will show up with a link to the medication notes
(typically recorded by support staff in the Medication review section). It’s note the same as the
“Taking differently” noted, which show up no matter what.

• Last administered will show the last time a facility-administered medication was given. Facility-
administered medications can also make use of the last Dose Request By, Request Dose Button,
Schedule Button and Administer Button columns. For example, if you order Depo-Provera, you
can use the Administer button to jump right from Meds & Orders to the MAR activity.

• Change/modify button will include a pencil icon column that will bring up the medication’s order
composer and allow you to change the sig; by default, when you sign it, it will re-order the
medication.

• Adjust sig button works like the change/modify button, but instead you get a lightning bolt icon
that defaults the order class to Historical med. (So, you can change the sig, and even the dispense
and refills, but unless you manually change the class nothing gets sent to the pharmacy.)

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 • Reorder button will tee up the medication for a new order, typically with the same instructions,
dispense and refills as previously used.
Reference
• Discontinue button gives you a column of ‘x’ icons that let you discontinue a medication. The last
guide four columns refer to functions that can all also be accessed by right-clicking on a medication. In
my experience, Reorder is the most useful one to use during a visit, since patients most frequently
will ask you for more refills of a medication.
Visit navigator
 The Review open orders link takes you to the Order review activity. Just below it is
the name column, which you can use to sort the medication list (within whatever
categories you may have defined in the List view, such as alphabetically by pharmacy
class). Click on the other column headers to sort by them (such a pharmacy or sig).

 The expansion arrows, when pressed, give you a brief medication report including the
dates, sig, and access to the reorder button and Request PA link for e-Prior auth. For
Facility-administered meds, you’ll get an “Administer” link to jump to the MAR.

 Click the Comments link to enter Medication list comments, which can be seen by
other users in most places the medication list is available. You might use this to note, for
example, “Avoid narcotics except for significant trauma.”

You can put in new medication orders by typing in the box (which disappears in Epic
2018, subsumed into the new Visit taskbar) and pressing the New Order button (or the
enter key, which is faster); you can add a new patient-reported medication with the
neighboring Patient-Reported button, as if it had been entered in Medication Review.
Note patient-entered medications get a distinct guy-with-a-speech-balloon icon, to
distinguish them from provider-ordered meds.

Pharmacy selection
Starting in Epic 2017, the pharmacy selection window, available at the bottom of Meds
& Orders next to the ℞ (Rx) icon, will let you select more than one pharmacy for a set of
orders.

Pharmacy link button

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 When you press it, you’ll get the following window (if you have no default pharmacy
Reference selected for this patient):

guide

Visit navigator

Pharmacy search window

You can search for pharmacies here by city, nearby zip codes, and 24 hour status. Once
you have a default pharmacy selected, you get the following dialog:

 Designate the default (primary) pharmacy for this patient with the blue diamond;
click on any pharmacy name to move it.

 Click on the gear icon to get a pop-up menu where you can change the pharmacy,
remove it from the list, or get the details of the address.

 In the main part of the window, by default all the medications will get sent to the
primary pharmacy. You can check off alternate pharmacies for one or medications
before signing.

 You can add an additional pharmacy to this window (and the patient’s list of
pharmacies) by clicking on the “Add Pharmacy” button, which brinbgs up the prior
Pharmacy search window.

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 Visit taskbar
Reference The Visit taskbar, introduced in Epic 2018, lets you order labs, imaging, referrals,
procedures, and medications without yanking you out of your current task in the Visit
guide navigator. You’ll rely on the Visit navigator to get at diagnoses to associate and the
problem list, which allows the taskbar to be a small, focused tool that still does a heck of
Visit navigator a lot:

 Add a new order here. You can click on the green + sign, but even quicker, type
Control-O. You can stack up a bunch of orders together into the shopping cart you see
on the right.

 The icon of circles with lines headed off to the right gets you into your Browse view,
with tabs to your preference and facility lists.

 The Print AVS button prints an after visit summary like you’d expect, on the way to
finishing your appointment. The “drop up” arrow just to the right give you additional
options to denote a patient declining an AVS, or previewing an AVS complete with the
ability to change the language in the headers, and changing the print size (default, large,
or economy-sized).

 The clipboard option lets you review signed orders, and reprint or cancel
prescriptions or orders. You also have a link to the pharmacy selection box nearby,
which includes a “Send to multiple pharmacies” button if (for example) some meds need
to be mail order and some need to be picked up straight away.

 If there are orders to be signed, this button will say Sign orders (shortcut, Alt-S). If
they are all signed, the button will say “Sign Visit” (shortcut, Control-S, which prevents
you from signing and closing a visit when you thought you were just signing some
orders). If you type Control-S while you still have items in the shopping cart, you won’t
sign the visit; you’ll open up the shopping cart instead.

The upward triangle to the right of the button will let you either Remove All the orders,
Selective[ly] Sign just a few so you can modify the remaining, or Sign and Schedule,
which will sign the orders and teleport you to the patient’s Appointment Desk.

 The orders shopping cart gives you a diagnosis association grid button on the upper
left (which includes being able to snarf diagnoses from the Problem list), a link in the
middle to Edit Multiple orders (like select some or all of your labs, set the
Future/Standing status to Future, and then put in an Expected date of 3 months from
now for the lot of them), a cost estimation box (if available in your system) next to that,
and an Options menu to the right (see below). The half-filled rectangle option expands

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 this action-packed shopping cart to an Orders sidebar. Either way, when you highlight
Reference an individual order, you have the option to “star” it onto a Preference list, or “X” it into
oblivion. The dropdown Options are as follows:
guide
Providers lets you order an item under someone else’s name (you’re still the ordering provider;
your victim is the authorizing provider who will get results, and, presumably, insurance company
Visit navigator flack)

CC results lets you add a list of interested parties who will get the results of labs and studies.

Interactions will match any medications in your shopping cart of extant ones on the list (and
compare to the allergies list too). Interactions your organizations has set to be serious enough will
show up anyway as a warning before you’re allowed to sign any orders.

Create panel lets you create your own personal Order Panel, like “Follow-up diabetes” which
might contain an A1c, BMP, and microalbumin. Order Panels don’t contain linked diagnoses and
can’t cross mode boundaries (e.g., no pharmacy and facility-administered meds together) as of
Epic 2018. Panels can be accessed from the Preference List Composer. Here, you can change the
details of each order (lab collect, routine priority), the display name, and uncheck or remove
orders entirely, but you can’t add new orders to a panel (as of Epic 2018). You can’t create new
panels outside of the Visit taskbar either.

Routing options. I hadn’t figured this out by press time. Stay tuned!

Financial pops open a report showing a benefit plan summary for your patient, and estimates the
quoted price and patient responsibility for the charges in the encounter. At press time, it didn’t
include medication cost Estimates available from the eponymous button in the shopping cart.

Medication review
The Medication review navigator section, known as “Medication Hx” prior to Epic 2017,
is designed to allow support staff to review the medication list with patients and record
whether or not they are taking medicines as directed.

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  Support staff can add patient-reported medications here. These don’t get printed or
Reference sent to the pharmacy; they just show up in the med list with a “patient reported” icon.

guide  You can check interactions of all the medications already on the med list with the
Check interactions button. The Informants button sets the default informant (like
patient, or mother) for reported medications here. You can use the Mark Unselected
Visit navigator
buttons to check or uncheck all the unanswered Taking/Not Taking buttons.

 Support staff can designate whether a patient is Taking a medication (as directed);
Taking it differently (which generates the yellow note, visible here and in Meds &
Orders, which disappears once the medication is re-ordered); or Unknown if you don’t
get a straight answer. These responses are only visible in the current encounter, except
for yellow notes which survive until re-ordering time. (In Epic 2017, you can delete med
notes in Meds & Orders.) When providers re-order or change a medication with Taking
differently notes, they’ll get the following box, allowing them to follow the original
instructions, the ones reported by the patient, or enter in new ones altogether:

 The purple check shows at a glance which medicines are being Taken/Taken
differently, and shows up in Meds & Orders too. The paper icon gets you to the old
medication note box, where you can put additional medication notes that probably
aren’t as useful as the newer Taking differently notes. The report icon shows you the
medication report (as in Meds & Orders). The X will discontinue a medication. It can’t be
undone, and many groups think support staff shouldn’t routinely use it, since it doesn’t
leave much of a trace.

Interaction checking
Epic can warn you about a bunch of different sorts of medication reactions: drug-drug,
drug-disease (using the Problem list), drug-lactation (if Breastfeeding isn’t marked No in
vital signs), drug-pregnancy (looking for active pregnancy episodes), drug-age/sex. It’s
typically set up not to bug you with pop-up warnings at ordering time about most drug
interactions time unless you attempt a real doozy, like warfarin-amiodarone:

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guide

Visit navigator

You’ll also get pregnancy warnings if patients have an active pregnancy episode. If you
want to know about less dire or common interactions, though, about existing items on
the medication list, you can “Check Interactions” button at the top of the Medication
Review section (known as Medication Hx prior to Epic 2017). You can also use the
Interactions button at the top of Order Entry.

Epic shows you the most dire warnings by default; you can click the “Show filtered
warnings” button on the lower left to show more. You can use individual override
reasons if this pops up at ordering time with each interaction, or override all of them
with one reason using the buttons below (or the drop down menu to the right, which
works the same but has a few more reasons). Your reasoning gets documented
somewhere and is probably discoverable in court, so choose wisely!

Charge capture
When you’re seeing a patient, you’ll typically record charges as a Level of Service for the
office visit, and there are charges “dropped” for any POC (point of care) labs done
during the visit. Sometimes you’ll need to add additional charges for procedures you do
during the visit (ear lavage, circumcision, colposcopy, toenail trimming, or fetal non-
stress tests).

You don’t have to use Charge Capture for these additional charges; you can just put in
the same CPT codes under Meds & Orders. The idea, though, is that Charge Capture
contains the common charges for your specialty and/or department. Still, that can be a
lot to navigate through. Many providers have maybe a dozen or so charges they
typically order. As of Epic 2017, you can store those on a preference list (accessed by the
Preference List Composer; mine, for example live on “Rosenberg, Daniel’s charges
preference list”):

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 As of Epic 2017, you can search for charges on your specialty’s preference list in Charge
Reference Capture:

guide

Visit navigator

Then, you can select one or more (with the Accept or Select & Stay buttons,
respectively), and add it to your favorite charges by pressing the “star” button before
accepting (or cancelling) the charges:

It makes sense to use a shorter, lucid display name when possible, as above. You can
make multiple versions of a single charge, with different quantities and modifiers, for
example. (You’ll get asked upon signing if you want to apply those defaults to the charge
you’re about to enter.) Favorites get added as buttons (or checkboxes, if you prefer to
change them with the wrench) that hang out on the top of your Charge capture
navigator section in the “My favorites” for easy pickings the next time you come
through:

You can add additional sections beyond My Favorites in the Charge Capture preference
list; these will show up further down in the navigator section, rather than up top. You
can use the wrench in the Charge Capture section to determine if just your Favorite
charges show up, or your other sections too (as well as your specialty’s list). In general,
the options available under “Personalize charging” from the wrench are explained with
tooltips that appear when you hover over the requisite buttons.

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Visit navigator

 Click this wrench to update Charge Capture settings. Note that if you make changes
to the underlying Charge Capture preference list, they may not be reflected here (even
with the refresh button) until you close then re-open a patient workspace.

 The “default charge information” display is this section which now optionally shows
up at the top of Charge Capture:

It contains the date of service (typically the same as the encounter date), charging
department and service provider. Epic wants you to “be smart” and choose the
eponymous button so this information only shows up when they think you need it. I
agree; consider using the Be Smart option. In general, you should not need to change
these defaults. You can always change the corresponding information in an individual
charge, like if you pop in and do an endometrial biopsy during another provider’s visit.

Select Condensed List if you just want your favorite charges (from the “My favorites”
section of your preference list) to show up, along with other sections on your personal
preference list. Select “Full list” if you want the department/specialty preference list
items (the traditional big list) to show up too.

 By default, the old Charge capture showed a bunch of charges with checkmarks.
You’d click on the checkbox to add the charge, and click on the name to both add the
charge and jump to a dialog box to associate it with the right diagnoses. The new-
fangled way makes the charges show up as buttons; click the big box to simply add the
charge, and click on the right side where a pencil icon shows up to get to the details so
you can associate the correct diagnosis. Since you probably need to set the correct
diagnosis, the old checkbox way may be better.

 Your charge buttons/checkboxes can be set up just to display the name of the charge,
or you can add the charge ID (the CPT® code number), and if you really want to annoy
yourself select Code which puts in not just the code number but the codeset it came
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 from—typically CPT®—which is a registered trademark of the American Medical
Reference Association, which licenses the use of these numbers, in return for money.

guide  You should probably display selected charges even if a section is collapsed to keep
track of what you’re charging for.

Patient lists  The “slim charge list” option saves screen real estate by removing the File charges
button, which you don’t really need since the charges get filed automatically, gets rid of
the filter options of files charges which probably few people use, and shrinks the
Refresh button to a simple icon on top. I’d use the slim version.

Patient lists
The Patient lists activity (Epic button > Patient care > Patient lists) can help you keep
track of patients several ways:

• A list of your own or your group’s hospitalized inpatients, with patients

automatically added and removed.
• Personal lists you can share with colleagues and support staff, like your current
prenatal patients.
• Historical lists you can use for privileging applications, like “My delivered
patients 2016.”

Patient lists activity overview

 Click the Edit list button to bring up a menu where you can create your own personal
“My list” folder to which you add and remove patients, edit an existing list, or remove a
list, as detailed below in Building your own list.

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Patient lists
 (For inpatient use.) The Sign out report button lets you put in a blurb for each patient
that your colleagues can see in their Patient lists activity. The report is printable, and
contains a stack of previous sign out reports, with the newest ones on top.

 (For inpatient use.) The Handoff report is a bit more detailed than the Sign out report
(and, I suppose, could replace it); it’s designed for when you rotate off a service. In Epic
2017, it adds a “To do – On call” list for your colleagues. Like Sign out reports, text can
be filed as progress notes in the chart and printed.

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guide

Patient lists

 Your personal patient lists (which may contain system lists) are in the upper pane.
Note there is a folder of Shared Patient Lists toward the bottom, where you can see lists
from your partners.

 Available system lists are in the lower pane. You can scroll down until you find your
hospital, and use pre-made folders, like specific hospital units in “All units,” or lists of
your own patients in “All my patients,” which includes lists of patients for whom you’re
the PCP, for whom you’re on the treatment team (e.g., as admitting or attending), and
combinations thereof.

Under “Provider groups” for each hospital you should be able to find your own, which
includes all of the patients attributed to your clinic. If you can’t find it, you can request

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 that such a list be built. Then, you can drag or drop one or more of these groups to the
Reference upper “My lists” pane, into one or more of the folders you create.

guide Building your own list

When you create a list, you’re really making a folder to which you can add or remove
arbitrary individual patients, as well as drag and drop system lists from the “Available
Patient lists
lists” pane, such as everyone in PPMC 3G or everyone attributed to PMG Gateway
Family Medicine. Each list you make (or copy) has properties: a collection of columns,
which can contain things like patient name, blood type, gestational age, and when the
last note was written. This process is detailed below.

Like your own personal clinic schedule, you can set a default patient list and customize
the columns of your various personal lists to your liking. This is the window that pops up
when you go to Edit list > Create My List, or if you use Edit list > Properties on an
existing list folder:

 Give the list a descriptive name. If you’re going to share the list, put your name in
there too, like “Daniel Rosenberg’s prenatal patients.” List names are global throughout
the system; everyone can see yours under Shared Patient Lists, and you can see
everyone else’s (but the owner isn’t otherwise obvious unless you right click and select
Managed Shared List).

 You can search for available columns with this box (in Epic 2017 and later). For
example, your Prenatal list will likely contain the patient name/age, gestational age,
room/bed, and perhaps blood type, EDD, ROM, dilation, and delivery date. If you think
Epic knows about some information (like gravida/para) that’s not yet a column, you can
request it be built.

 Available columns are in this top pane; you can request they get added to the bottom
pane by double-clicking them or using the Add button.

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  If someone else already built a nice list folder, for say, newborns, with their weight,
Reference admission time, birth GA, and delivery type, you can use the Copy button to copy over
someone else’s column definitions onto your list:
guide

Patient lists

You just need to know what they called their list. (See .)

 You can remove columns with the remove button, and re-arrange them with the
arrow buttons (up and down here translates to left-and-right in the list definition).

Sharing patient lists

If you click on the Advanced tab on the top of the list-building activity, you can allow
others to share your list folder (not just the columns, but the actual patients in it):

 The default list report is the one that shows below when you click a patient’s name in
a list above.

 You can give individual users (on the left) access to your list, with varying levels of
permission on the right. Those permission levels are:

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 • Add/remove patients. Allows the user to add new patients to your list and get rid of existing ones
(from the list). You might use this for trusted support staff.
Reference
• Change accessibility. Allows users to share/unshared your list with third party users.
guide
• Delete patient list. Allows users to delete the list itself.

Patient lists • Modify properties. Allows users to change the columns in your list.

• View only. User can only see the list, not change it. You’d use this for most of your colleagues.

Setting a default list

You can right-click on any of your list folders to make it the one that shows up by default
in the Patient lists activity:

Remember, any list folder can contain not just arbitrary patients you add and remove,
but one or more system lists you drag and drop into the folder.

Adding and removing patients from a list on the fly

The Patient Lists activity, above, is great for building and keeping track of patient lists.
You can also add and remove arbitrary patients. But if you’re in a patient chart and think
they needed to be added (or removed) from a list, it’s not convenient to head to the
Patient Lists activity, figure out which list to use, and add/subtract from there.

Instead, use the Patient List Membership activity, under More (Activities) > Patient List
Membership:

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 This activity assumes you are talking about the patient whose chart you are in. In this
Reference example, the patient is on my list of pregnant patients, but it turns out the ambulance
took her to an outside hospital instead of where I deliver, and she now has a bouncing
guide baby girl. I’m going to uncheck her from my Pregnant list, and check the box next to
“Delivered by others” instead:
Orders preference
lists

Orders preference lists

As a clinician, you’ve got two main jobs to do in the EMR: write notes, and order stuff.
The number of things you can order is lengthy, which is why it makes sense not to slog
through the entire list of possible items every time, for example, you order a Pap smear:

Rather, you want to choose from a well-maintained, vetted list:

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Orders preference
lists

When you put in orders, you’ll notice a 3-4 tabs at the top of the window. Above is the
Preference list view, which puts together items on your own personal preference list
with those on a system list for your specialty (like Family Medicine). The browse view is
analogous to the old check-off lab forms of yore:

It comes with an “Only favorites” button at the top that restricts the display just to the
items on your personal preference list, leaving off the system specialty preference list
items.

The Facility list is a shorter list of items. For labs, it’s typically the items that your local
hospital lab does. It may include imaging studies only when used from an inpatient
chart, and no referrals. The Database tab is the wild west, which contains every item
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 available at every internal and external lab used in your health system, which means if
Reference you order an item in Oregon that’s only available in rural southeastern Washington,
your order is going to gum up the works and result in frustration for you, your patient,
guide and the lab. In other words, don’t order labs, x-rays or referrals from there.

That means at a big institution like Providence, you’re usually going to use the
Orders preference
Preference list, but even that can be unwieldy. If you want someone to see a local eye
lists
doctor, your search for an appropriate referral will stretch from Portland to Newberg,
even though you might only use 3 of the 38 available items:

There are two strategies I recommend. The first is you could spend the time, energy,
and whatever it is that makes nerds tick to build and maintain your own list. I’m going to
show you how to do this, but a simpler strategy is to borrow someone else’s
preferences instead. Either way, I need to introduce you to the Preference List
Composer (Epic menu > Tools > Patient care tools > Preference list composer). Don’t
confuse this with its sibling, the Preference List Editor, which manages lists of non-
orderable items, like favorite diagnoses and chief complaints.

Preference list composer

The Preference list composer is where clinicians can keep track of their favorite orders
for imaging, labs, medications, referrals, and a general Orders preference list which
stores ad hoc items you save by “starring” an order before signing it. Each of these is
called a list. You’ll see your collection of lists when you first fire up the Preference list
composer.

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Orders preference
lists

The Preference list selector window in the Preference list composer

Copying preference lists

You can use the Copy User button on the lower left to look at anyone else’s preference
lists in your instance of Epic, and, if you want, copy them over to your own lists.

Preference list composer copy user window

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  The first box is the user you’re copying lists from. Put in the name of a preference list
Reference nerd near you here.

guide  The second box is the destination user. It usually should be you. If you’re going to
copy onto someone else’s list, you might ask them first.

Orders preference  There are two “copy options” to choose between when copying a preference list.
lists Merging adds the source list to the destination list, except for exact duplicates.
Replacing blows away the destination preference list and replaces it with the source list.
It’s not as messy, unless of course there was something on the destination list you
wanted to keep, in which case it’s more disastrous. There’s no undo here. Don’t do that
to other users unless you are certain you know what you’re doing.

To see what’s on another user’s preference list, follow the directions in the lower left
corner of the window, and double click on the number cell (like 432, above) to see the
contents.

 In the title of the window, you can see we’re looking at James Chong’s outpatient
Labs preference list. It’s a heck of a list!

 In the left column, you can see he’s got his Labs list divided into Sections, some of
which (“Liver related”) have Subsections (“Abnl LFT”).

 In the main pane are the contents of the list. There’s no additional details: what you
see here include the order number on the left, the display name in the middle, and the
guts on the right.

The Frequent orders list

There’s also a semi-hidden list called “Frequent Orders,” which stores items you’ve
ordered repeatedly. (Typically more than 5 times, even if you ordered an item in error,
like if you keep ordering a Tdap of the sort that gets sent to the pharmacy when you

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 meant to give the one available in clinic.) Frequent orders pop up as suggestions when
Reference you’re typing in Meds & Orders:

guide

Orders preference
lists

Suggested orders come from the automatically-maintained “Frequent orders” list

They also show up with green triangles next to them when ordering from the Preference
list tab:

Green triangled orders come to you from the Frequent orders preference list

You can access this list from the Browse view, and right click to remove items from it.
You can also right click items in the browse view to move them to another list (which
you can’t do in the Preference list composer):

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Orders preference
lists

Right-clicking in the browse view lets you move orders from one list to another, and remove orders from the
otherwise hidden “Frequent orders” list

The Frequent orders list, since it’s maintained by Epic and not by you, only shows up if
you have the “Only favorites” box unchecked.

Bed meds preference lists

Items administered during a visit are (in versions of Epic up to 2014) stored in inpatient
preference lists, even for an outpatient clinic. So if you want to store a list of your
favorite in-clinic immunizations, use a list named something like “Rosenberg, Daniel’s
Orders preference list IP.” (If you star these orders before signing them, they’ll likely end
up here.)

”Inpatient” preference list used for “bed med” outpatient orders

Make multiple versions of one item

You may frequently use the Uncoded26 item, for example, to set up compression
stockings orders. There’s a lot of fluff to fill out (1 each, continuous frequency, Manual

26
The equivalent for labs is “MISC REFERRAL.” To avoid driving your colleagues in the lab
bananas, whether you’re ordering a one-off or making a preference list entry, copy and paste the
information out of your reference lab’s test directory into the order Notes, like “Juvenile
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 fax) but you could put in several of these with knee- and thigh-high varieties, with
Reference different compression strengths, and save them with varying display names. They are all
version of the same order, but now you don’t need to fill out the details each time.
guide Following are some examples I use of multiple versions of the same order:

Orders preference
lists

Multiple versions of acyclovir and valacyclovir, with indications in the display name

I find remembering which antiviral dose and duration to remember for shingles, HSV 1
and HSV 2 is tough, so I saved them as preference list entries. I can put “HSV2 recur” in
Meds & Orders and get a reasonable list of options.

Besides pre-filling in pill sizes, frequencies, and durations, you can also pre-fill in order
information boxes:

Pap smear orders: two versions of the same thing, and two GBS orders

Group B strep tests need to be ordered differently if patients are penicillin-allergic to

make sure that sensitivities get run. You can save a version of that order on your
preference list:

polyposis (SMAD4) Sequencing, ARUP 0051510, 3 ml whole blood, refrigerated, lavender EDTA
tube.” For ARUP, see aruplab.com.
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Orders preference
lists

To prevent myself ignoring this, I refer to penicillin allergy in both versions of the display
name of my order to make sure I have it in mind at collection time.

The 2013 ASCCP guidelines on cervical cancer screening are complex, and easy to get
wrong at ordering time. I found that by using 2 copies of LAB1790 with detailed display
names, I could keep this straight and take better care of patients:

Pap smear order for 21–29 year olds; reflex HPV if ASCUS

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Orders preference
lists

Third version of the same order: 30–65 year olds should usually get co-tested with an HPV assay per ACOG.
Note you can help out the lab by using the @LMP@ SmartLink in the order composer, which helps
cytologists read the Pap.

Lab preference lists: where the Preference list composer lets you down
In a large health system like ours, lab orders get performed in lab in a nearby affiliated
hospital. Different labs may vary in the analyzers they have around, so sometimes a test
available in one place isn’t available exactly the same way elsewhere. You can see all the
lab tests available in all of your organization’s labs on the Database tab—including ones
you aren’t supposed to use. The Facility tab only contains the ones available at the lab
your tests are actually performed at.

Correct “Tissue path” order from Facility tab (LAB1750 in Oregon)

The correct order from the Facility tab in Epic 2017

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Reference
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Orders preference
lists

Asking for trouble on the Database tab

Asking for trouble on the Database tab, Epic 2017

As a result, providers should order their labs from Facility tab, or from a preference list
that only includes labs available on the Facility tab. If, instead, you search on the
Database tab, you may get an order that looks correct but will result in an error or delay.
Either the lab won’t get performed or the lab staff will need to figure out which version
of a local lab is closest to what you ordered, gumming up the works.

This is a problem when building preference lists. In the EpicCare Ambulatory Preference
List Composer, when you “Add an item” only the Database tab is available (as of Epic
2017). This boils down to the following: don’t use the Preference List Composer when
building a lab preference list, at least initially. Instead, order one or more labs from a
patient chart you want to add, and before signing, press the “star” button to add each
item to a Preference list.

For example, search for the labs in a real (or fake) patient chart:

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Orders preference
lists

Be sure you’re on the Facility List tab! You can press the “Select & Stay” button to tee up
multiple labs you want to add to a Preference list. Then, before you sign the order, press
the star icon:

This brings up a details window, where (rather like the actual Preference list composer)
you should fill in every single available detail and change the display name to something
distinctive (so when it comes up in a search result you know it’s a personal preference
list entry).

You also should pay attention to the destination Preference list on the upper right:

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Orders preference
lists

By default, your entry will end up on the “Orders” preference list, which is kind of like
sticking all of your clothes in one giant drawer. Later on, when you need to get dressed
in a hurry, you’re going to need to search through your scarves and mittens in July to
find your swimsuit.

For labs, use the “Labs” preference list instead of orders, and either use one of your pre-
existing sections or click the “New” button to make one. You can use the Preference List
Composer later on to re-arrange the furniture, knowing the pieces you’ve selected were
legitimate denizens of the Facility tab. Note that you can click the magnifying glass to
get a list of your existing sections and subsections:

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Health maintenance

At least of Epic 2017, this selection box doesn’t make any distinction between sections
and subsections (in this example, Screening is actually a subsection of my Peds section).

Ordering sendout labs

If you can’t find the order you want, you can use the “MISC LAB REFERRAL” order, which
is the standard way to order esoteric tests from reference labs. You can use the Epic
Procedure Catalog to look these up (Epic menu > Tools > Lab tools > Procedure catalog),
though personally I find using the test directory for a reference lab easier for sendouts,
such as www.aruplab.com. Fill in the details in the order with the test number and
name, such as “ARUP 0055340, allergens, food, salad profile. SST, refrigerated.”

If you order a sendout lab frequently, you can save it as a preference list entry (since
you can save multiple versions of the MISC LAB REFERRAL order, using distinct display
names and contents, similar to the Pap smear example, above).

Health maintenance
The Health maintenance activity (More activities > Health maintenance) keeps track of
preventive care topics for your patients. Topics, like Pap smears, mammograms,
immunizations, and colon cancer screening are defined at the system level, and then
Epic keeps track of whether your patients have “satisfied” these topics by checking for
appropriate results, documented immunizations, and procedures. Individual topics, like
colon cancer screening, might have several different plans, like colonoscopy every 5
years, colonoscopy every 10 years, and fecal occult blood screening every year.
Sometimes Epic itself will switch a plan depending on the results it finds; more often
clinicians switch the plan by adding a “health maintenance modifier” to the chart, like
“Pap smear every 6 months.” Different patients will get assigned different topics:
women27, for example, get Pap smears and mammograms, and people over 6 months
get a flu vaccine topic.

27
As of Epic 2014, the “Sex” field (corresponding to the legal sex of the patient) determines
which Health Maintenance topics get applied. Starting in Epic 2017, there will be opportunity for
applying topics more appropriately to transgendered patients with the use of an additional
gender identity field. An assigned gender at birth field, upcoming in a subsequent version of Epic,
should help us more appropriately assign Health Maintenance topics, though much of it we’ll
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Health maintenance

 You can use the Postpone button to stop bugging patients about a topic they can’t or
won’t get done soon (like mammograms if they are overseas until spring). Select a topic
(by clicking on one of the rows at ), then click the Postpone button. You’ll then be
prompted to enter a Postpone until date, and a reason, like “Patient declined” or “Plan
in place.” You can remove postponements before their expiration date by using the
Remove Postpone button.

 The Override button may allow you to “satisfy” a topic (with a reason like “Done” or
“Not indicated”), but it also won’t fulfill quality measures; it’ll just get the topic out of
your face until it comes up again. You should avoid using this if possible, and document
elsewhere instead. For example, document outside Pap smear in the External Results
Console (More Activities > External Results Console). That makes it easier to track what
actually happened with these topics over time (and counts for quality indicators).

 If you click on the “Document past immunization” button, you’ll be redirected to the
Immunizations activity, where you can enter historical immunizations by type and date.

 The Edit Modifiers button allows you to change Health Maintenance plans as clinically
appropriate. It isn’t paying attention to any topic you have selected. Click the magnifying
box and enter a likely search term, like colon or cervical:

likely have to do by hand by watching for sex, gender identity, and assigned gender at birth field
differences.
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MyChart

This is how you assign higher risk patients to more frequent screening. (One day, I
suppose, Epic might do that for you; pray it doesn’t make you obsolete altogether.)
Some modifiers may get assigned for you in the background, like “Not a candidate for
varicella vaccination” if Epic finds a history of varicella in the past medical history.

 The Update HM button will become active if you make changes to a patient’s record
that could change what Health Maintenance topics are due, such as administering an
influenza vaccination. Normally, Epic checks everyone’s chart around 2 am or so while
you’re asleep updating which topics are satisfied for patients, but if you want to see the
Health Maintenance activity updated sooner, click here. (This will also update associated
BestPractice Alerts, and SmartSets that pay attention to Health Maintenance.)

 The list of topics shows which ones are active for a given patient, when they are due
(which may be a date years in the past for something that’s never been done), icons to
show which topics are due soon or overdue, and dates that the topic was previously
satisfied. In the pictured example, this patient is due for their seventh tetanus booster
as a Td vaccine in August of 2024.

 Health Maintenance modifiers active for this patient, as described in , are listed
here.

MyChart
Result release
The mechanics of releasing results are addressed in the In basket section above, under
Result Release. One last item to be aware of: if you want to go back and re-release, un-
release, or review whether a patient has read her results, use the More (Activities) >
MyChart > MyChart Results Release activity from inside a patient workspace. You can
prevent the automatic release of results here, and see who released what, when.

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MyChart

 The green checkmark indicates a result was released to the patient, but not yet read.

 A binoculars icon (eyeglasses in prior to Epic 2017) shows that a result was released
and viewed by the patient; if you hover or click to expand the item, you’ll see when. If
there are result comments that the patient read, you’ll get a second, fainter binoculars
icon, and in the expanded result breadcrumbs about when the patient read your
comments.

 A clock icon indicates a result is not yet released; if you hover, it will tell you when it’s
scheduled to be automatically released

 A clock icon with a checkmark indicates a result that got automatically released per
your system’s schedule. There’s usually a brief interval for normal lab results, and longer
intervals for abnormal results, imaging and pathology.

 You can individually release unreleased results, and unreleased released ones, using
these buttons.

 Click here to prevent automatic release of a result (that is otherwise scheduled to be

released).

Reviewing sent messages

You can review previously sent and received MyChart messages in Chart Review >
MyChart. But, you’ll get only a limited idea of the thread of a conversation (each
message and its associated reply is in single entry, with only the subject lines to
distinguish them):

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MyChart

While you can change those message subjects when you’re writing them, most people
don’t bother, so you end up with a lot of “RE: Non-Urgent Medical Question.”

Instead, you might try More (Activities) > MyChart Utilities > Patient Message Review,
where you have three ways of looking at messages. The default way puts your messages
on top, and the patient’s on the bottom:

Default MyChart Message Review view

The detailed version puts in the text of the messages for context. It still puts your
messages at the top, and the patient’s below:

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MyChart

Detailed view

The “mixed” view is closest to the way I think: the messages are in the order of their
creation, no matter who sent them:

Mixed message view

And the “mixed detailed view” is the same, but with all of the text showing. Note the
binoculars button on top, which you can use to find text in these messages. Unless you
just care about the text of the subjects of the messages, you need to select one of the
detailed views (by clicking on one of the links in the first row) before you click on the

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 binoculars, since this function will only find text if it’s actually displayed on the screen.
Reference Chart search does not work on MyChart messages as of Epic 2017. In fact, in most places
in Epic, you can type Control-F to find text displayed somewhere on the screen.
guide
MyChart proxies
MyChart is invaluable for allowing patients and clinicians to communicate back and
MyChart
forth about test results, symptoms, and appointments. MyChart requires that the
patient have an email account they read to get notifications, and the skills to navigate a
web browser or the MyChart app running on their phone. Some patients, though, may
be too young, too grumpy, too distracted or too technophobic to use it on their own.
These folks can have “proxies,” where someone else who is willing to read their own
email is granted access to a patient’s chart. Proxies come in several categories:

• Adult accessing adult. This could be an adult child helping out their aging
parent, or a responsible spouse helping out their husband who doesn’t reliably
read his email. For adults accessing adults, our institution requires a signed
letter from the patient granting the proxy access and informing them they can
revoke that access at any time.
• Adult accessing minor. Parents reasonably want to communicate about their
kids’ sniffles and rashes. In my institution, they can do that up until the child
reaches age 12, after which parents typically are denied access to protect the
privacy of their child. 12-17 year olds, though, can get their own, limited
MyChart access.
• Adult accessing diminished capacity teen. For parents/guardians of disabled
teens age 12–17 at our institution, they may need access to a minor’s chart in
order to communicate symptoms and coordinate care. We do this by
establishing proxies of this type, and applying a “Disabled” Patient FYI flag to the
teen’s chart.
• Teen parent accessing child is used at our institution to let teen moms and dads
have proxy access for their own children. (Normally, teens have limited MyChart
access in our system, allowing only messages to and from providers, and
scheduling appointments.)

You can view proxy relationships from either the proxy’s chart (e.g., the adult of a kid) or
the proxied chart (the kid), via More (Activities) > MyChart Utilities > Proxy Access:

A person can be both a proxy for someone else, and have their own proxies (who can
only see the proband’s chart, not further down to their proxies). To add a proxy to a

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 patient’s chart, go to their chart, and get into the Proxy Access activity, and click the Add
Reference button:

guide

MyChart

You’ll select the relationship type from the list above (or something like it), and click
“Proxy lookup” to find the person who will be the proxy:

Even if the proxy says they aren’t a patient at your institution, click the Patient box first.
There’s a good chance they’ve registered at one point or another and their information
is readily available. Verify it’s really them with an appropriate birthdate, precise name
and address. If they aren’t in the database, you can always go back and make them a
“non-patient” account (also with a name, address, and birthdate—also search for an
existing non-patient record first).

Once you’ve linked the proxy to the chart, if the patient does not otherwise have an
active MyChart account, you need to enable proxy access using the button on the upper
left of the activity:

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 If your proxy can’t access the chart, check to make sure you clicked that button. Even
Reference then, you still won’t be able to send messages to the associated MyChart account until
the proxy has logged into the chart for the first time. You might want to do that before
guide the proxy leaves the office.

When a person with proxy access logs into their MyChart account, they’ll get extra tabs
MyChart
besides their own—on the right in the web version, and on the bottom in the
smartphone app:

Proxies should be sure to click the button to get into the tab for the right patient when
sending messages, otherwise they’ll risk mixing questions and answers about someone
else in their own medical record. Once they are in the proxied patients chart, they can
send and receive messages, view labs, and cancel and schedule appointments on that
person’s behalf.

It’s worth gently reminding proxies about this when they forget, especially since you
expose yourself not only to accusations of substandard medical care, but kneecapping
by the HIM staff.

Parents will understandably complain when they can’t send in a message about their 12
year old. (Even though 12 year olds in our institution can have their own teen MyChart
accounts, not all of them are ready to write you a detailed missive about their knee pain
or menstrual cramps.) But, because teens can consent to health care (the specific
varieties vary from one state to the next) and there are cases where parent notification
would pose an obstacle to care, teens also have an expectation of privacy (albeit with
legal limits). A minor is a protected individual under the HIPAA privacy rule if they have
consented to health care and are legally permitted to do so, or when the parent has
assented to a confidentiality agreement.28 You have my sympathy about the annoying
consequences of these good intentions.

28
English A, Ford C. “The HIPAA privacy rule and adolescents: legal questions and clinical
challenges.” Perspec sexual reprod health 36(2): 80–86. The Guttmacher Institute also publishes a
summary of minor consent laws by state.
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 Episodes of care
Reference An Episode is a way Epic can bind together a bunch of related encounters. Some
encounters (like pregnancy and anticoagulation) aren’t fully functional unless they have
guide a related episode. You might have multiple instances of one sort of episode per patient:
each pregnancy, for example, gets its own episode.
Episodes of care
Episodes allow billers to figure out global fees, for example, for prenatal care, and you
can generate episode reports which can summarize anticoagulation management or a
pregnancy across encounters. The latter is the sort of thing you might find yourself
faxing to another hospital, for example, if your labor deck is on divert. An example of
the anticoagulation episode report is below.

This is the first part of a pregnancy episode summary:

If you scroll through it, you’d also find prenatal labs, the flowsheet of visits with fundal
heights, fetal heart tones, and symptoms, and the checklist of OB counseling (account
cats, contraceptive plans, and circumcision, among others).

The Episodes of Care activity, accessible by More (Activities) > Episodes of care lets you
view and edit associated visits (encounters) and Problem list items.

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  The first three toolbar items let you create a new episode of any type, or resolve a
Reference completed one. For example, I resolve the pregnancy episode at the 6 week prenatal
visit, which closes out the global billing period; you could also resolve an anticoagulation
guide episode when your patient can go off warfarin 6 months after their DVT. Don’t delete an
episode, unless it was created in error. N.B.: Most systems automatically resolve their
Anticoagulation pregnancy episodes a few months after the expected date of delivery.
navigator
 You may want to link visits to an episode. Prenatal and anticoagulation visits will
prompt you to do so (by suggesting politely at first, then preventing you from
documenting the visit until you’ve linked the encounter to an appropriate episode type).
Sometimes you may want to link related telephone or Documentation encounters to an
episode, which helps bundle notes together. If you press the Link button, for example,
inside a telephone encounter when a prenatal patient calls about cramping, the default
encounter to link will be the one you’re in, and when you open up the next prenatal visit
the telephone progress note will show up in the flowsheet area.

 You can see episode reports (as depicted above) using the button on activity toolbar
or the Episode Report tab below, or in Chart Review > Episodes, and in certain
Snapshots too (like Prenatal episode report).

 You can view the patient Problem list and link individual problems with the episode.
(There’s also a checkbox in the problem’s details on the Problem list.) This may help
with billing, and it can automate adding the visit diagnosis for appropriate encounters,
like prenatal visits and anticoagulation.

 Episode details can be edited here. It makes sense to give distinct names to
Pregnancy episodes so you can tell them apart later. The buttons to the left let you
group episodes by type, hide/show deleted and resolved episodes, and expand/collapse
sections of the episode list.

Anticoagulation navigator
If you’re managing warfarin for your patient, you’re going to use the anticoagulation
navigator. It’s worth knowing how to do this properly, since guesswork could lead to
error, which could lead to problems all around.

At Providence, there’s two ways to see the Anticoagulation Navigator: from More
(Activities) > Anticoagulation, or by making an Anticoagulation Telephone encounter.
Either way, you’ll need an Episode of care to bundle the encounters together, and if one
doesn’t exist, you’ll be prompted to make one:

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Anticoagulation
navigator

Click the “Create an Episode” button:

 Choose a goal INR, like 2.0-3.0.

 Choose an end date, like “m+6” for 6 months from now, or Indefinite if that’s how
things are going to be.

 It’s polite to put in indications. Your chart is a temple, not a swamp. Think about what
you’d want to see in your mother’s chart that would enhance safe cross-coverage.

 If the patient doesn’t show up, a pool somewhere gets notified to start making calls.
Where I am, that’s “PMG Disease Management.”

 Add one or more responsible providers, so the support pool knows who’s in charge.

My filled in episode looks like this:

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Anticoagulation
navigator

From now on, when you enter the Anticoagulation navigator (with an active
anticoagulation episode) you’ll get something more like this:

 A link to the episode is on top. If you want to edit it, use the “Edit episode” link on the
upper right.

 Your support staff will use the Patient findings to inquire about things like bleeding or
missed doses:

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Anticoagulation
navigator

 You do your work in Anticoagulation tracking, which looks like this:

 The top section is where you note the most recent INR result. Use the POCT button if
you’re doing point of care testing, or External to report results from outside labs. If Epic
finds a likely internal lab result, it makes it a button for you to click, verifying that’s the
result you want:

 Next, you choose a maintenance plan. If none yet exists, you’ll click on the None link
and make one. If it does exist, you’ll get a summary of it, which you can change by
clicking on the blue text or the pencil icon:

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  If all is well and the plan looks good, you can just click the No change box.
Reference  Select the date of the next INR here. You may have shortcut buttons for 1–4 weeks,
guide or other labels as shown.

 If you have any comments, you can put them here, like “Stable INR, eat the usual
Anticoagulation amount of fruits and vegetables, recheck 4 weeks.” If you have a Progress notes
navigator navigator section, you can use that if you like to add comments that get stored as a
progress note, but the official instructions should go here, and your support staff should
have a good understanding of that. Anticoagulation is not a good place for ambiguity or
conflicting instructions.

For similar reasons, it’s important to get the maintenance plan (referred to at ) right:

 The top refers to the size of the tablets the patient has. Most people will use one size
(like 2.5 or 5 or 7.5 mg tablets) to prevent confusion; you don’t need to fill in both slots
if that’s the case.

 If you’re temporarily not going to use a maintenance plan, check here, and put your
specific instructions down in the Details box noted above.

 Some patients get lucky and use a daily regimen of one size tablet, and a few patients
may use an alternative regimen, like 1 tab today, ½ tab tomorrow (repeats can be of
arbitrary length, like a 3 day pattern of ½, ½, 1; ½, ½, 1). Most patients will end up a
weekly regimen, pictured.

 For a weekly or repeating regimen, you’re entering the number of tablets per day,
not the dose in milligrams. If you can’t remember, look at the labels: you’ll note the
legend “tabs” next to each of the boxes, with the dose calculated below. It’s worth
double-checking here, especially for new regimens, to make sure you get this right.

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 Usually, you’ll route the encounter off to your support staff to contact the patient and
Reference let them know about any changes in the regimen, and hear about any bleeding or
bruising in return.
guide
Viewing the anticoagulation episode
An easy way to monitor the regimen is by looking in Chart Review > Episodes at the
Anticoagulation
Anticoagulation episode. It will show a few months of the calendar with the dosing and
navigator
INR results displayed:

And if you scroll down you’ll get the anticoagulation flowsheet with recent INR’s and rhe
resulting regimen:

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Infusion navigator

Infusion navigator
The infusion navigator lets you bundle a bunch of orders together needed for nurse-
administered therapy, like blood products, IV rehydration, or (say) iron sucrose. Because
infusions usually require more than just an order to hang a bag of something, the plans
can include:

• Labs
• Pre-treatment (like diphenhydramine for blood products)
• Monitoring parameters (call me for a horrendous rash)
• An infusion, with one or more medications or blood products, along with
administration instructions (IV push, or over 2 hours), with any needed intervals
• PRN medications, and instructions to be released in the case of reactions

You can make your own plan (for antibiotics if one doesn’t exist, or for a bag of normal
saline) using the “Create blank plan” button, or use one of the pre-existing plans, which
use the following naming convention at Providence: (PED) – class – generic medication
name – details, like “ENDOCRINE – PAMIDRONATE” or “REPLACEMENT – IRON SUCROSE
– 1000 mg (3 doses).”

Let’s say you’re planning on repleting the iron stores of a third trimester pregnant
patient with iron sucrose. From a visit (or orders only encounter) go to More (Activities)
> Infusion Orders.

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Infusion navigator

 You can search for therapy plans in the text box on top.

 If you want to make your own plan, perhaps for something simple like a liter of
normal saline, click the “Create Blank Plan” button.

 The pre-built plans are listed under “Available,” like my 1000 mg over 3 doses
favorite of iron sucrose.

I select my favorite, iron sucrose 1000 mg in 5 doses:

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Infusion navigator

 We’re starting tomorrow (as soon as you enter t+1, tomorrow’s date will show up in
this example).

 Many infusions will be given in your outpatient infusion department; our facility likes
to have the pregnant ladies go to Labor and Delivery in case there’s any funny business.

 Choose one or more diagnoses for your plan (it helps with billing and so people know
what you’re up to).

Next, the pre-built plan is displayed for your review:

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  The summary of the therapy plan shows up red to warn that you have signed
Reference anything yet. Check the box, and you’ll check off the included components of the plan
below (or just check off the ones you like). Note the “Help” order which is just there to
guide remind you what to do.

 Under the Actions menu, you can go back and change the Properties of the plan,
Infusion navigator
which is the previous screen with the diagnoses, start date, and location.

 Note the details of the plan: we’re going to 200 mg iron sucrose over 60 minutes
each, one per visit. If that looks good, click the Sign button. You’ll be asked to verify the
diagnoses and that you’re the ordering provider and authorizing provider. (Remember:
the ordering provider is whoever puts in the orders, and the authorizing provider is
whoever is actually responsible for them.)

Once the plan is signed, it turns green:

You can click on any of the orders to change the details (including the medication, dose,
and intervals). You’ll then be asked to sign off any changes. Remove orders by clicking
on the ‘X’ icons to the right, and change the order of components with the arrow icons.

If you’re rolling your own plan, select the Create Blank Plan button shown above:

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Infusion navigator

Give your plan a name, like IS NS 1L, and an associated diagnosis:

 Your plan name and start date shows up here.

 Search for a likely infusion order, like normal saline infusion. Choose something from
your preference list or Facility list to decrease the likelihood of curious calls from your
outpatient infusion unit.

Fill in the appropriate details of the order, noting the helpful hints left for you:

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Reporting

Reporting
Reporting Workbench lets end users (that’s you!) plow through Epic’s database to look
for interesting data (patients with A1c’s above 30, or the diagnosis Y921.46, hurt at
swimming pool of prison). This section will cover the high points and how to generate
basic reports. The details are available as 3 day course the next time you’re in
Wisconsin, or you can enjoy the AMB 502 Training companion from the comfort of your
home—all 512 pages of it.

My Reports tab
To get to Reporting Workbench, go to Epic menu > Reports > My Reports. This will start
you off in the “My reports” tab, shown below. In general, the order of ceremonies is to
get at existing reports you’ve made or modified in the “My Reports” screen below, and
if you don’t already have what you want, building your own report off a pre-existing
example or blank template in the second (Report library) tab.

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Reporting

Reporting Workbench: My Reports tab

 You can make folders (using the “Create new folders”) button to organize your
reports—worth doing if you’re going be spending more than just a little time here.

 Reports you’ve “starred” (down on the left side of ) end up here, sorted into folders
if you’re using them. You can rearrange them among folders by grabbing the textured
dots and dragging and dropping.

 Reports can take a while to run—sometimes 15 minutes or more, depending on what

you’re looking for. The bottom pane shows running reports and recently resulted
reports. You can double click on them to view them. If you built and ran a new report
(see below) it will show up here when you run it, but it won’t be saved as a favorite until
you click the star on the left. (It will still be in the database, just harder to find.)You can
right click and save resulted reports for later, otherwise the results will disappear in an
hour or two.

Report library tab

The Report library is where you can find report templates you can build off of, and
reports created by other users that you can run and copy and modify for yourself. Most
end users can’t publish their own reports for everyone to see: only folks who have an
Epic Clarity (reporting) certification are thought to be trustworthy enough to generate
reports that may actually generate truthful information. (It’s surprisingly easy to turn
out accurate-looking junk.)

Epic 2017, however, will let you share your results with a few other users, so if you
come up with something on your own you don’t have to make your colleagues re-create
the report to see the results.

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Reporting

 Search for pre-existing reports and/or templates here. Reports come in several
flavors, depending on the sorts of things you’re looking for. Most of them are built off of
a few basic templates, such as these (examples from my institutions; others may vary):

• Find patients. Templates starting with “Find patients” in them will return a list
of patients who meet the criteria you specify, such as those with diabetes who
smoke marijuana and drink a lot, or patients who viewed their progress notes in
MyChart in the last 2 weeks, or who had a shared decision-making discussion
about prostate cancer screening in the last quarter. Most of your reports will
probably be of the “Find patients” persuasion.
• Appointment search. Epic, being at heart a big database, keeps track of all
appointments—upcoming, cancelled, past. If you want a report of all of your
Annual Wellness Visit appointments in the last year, it’s probably easier to
search for appointments than searching for patients who had a specific
appointment type.
• Encounter analysis. This template doesn’t find all sorts of encounters—just
appointments. It’s a simplified version of the Appointment Search template. It’s
easier to use, but not as specific.
• Find orders will look across your department (or hospital) for orders—maybe
you want to analyze all the ceftriaxone injections, or sildenafil prescriptions.
• Lab component results / lab organism results. If you’re looking for all of the
positive gonorrhea results or hemoglobin A1c’s > 30, you would use one of
these templates.
• Provider search. If you’re looking for a provider, say all of the female Epic-using
psychiatrists licensed in Montana, you’d use a Provider search template. (Unless
Googling them would be easier.)

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 • And many more. You can search for Best Practice Alerts, charge reconciliation,
Reference people who “broke the glass” to look at psych notes, episodes, In basket reports
of incomplete charts, OR cases, accepted insurance claims, and Patient FYI’s
guide (among others)

Reporting
 Check the “Show templates” button to see report templates (then use the Expand
button at  to hide everything but the templates vs showing all the associated reports).
Uncheck the “show templates” button so your search results show only the reports
themselves. I find you’ll usually want to see the templates, so I keep that box checked.

 Filter the reports you are searching for: you can look just for your own reports, or
specific types (which you may find confusing and better left alone).

 When you find a promising looking template you can highlight it to display the “New
report” button to generate your own version. If you highlight a report (and not a
template) here instead, you’ll get two buttons: Run (to run it as is) and Edit (to make a
temporary version with modifications you can run, or save to your own favorites).

Creating or editing a report

First example: Shared decision-making for prostate cancer screening
The best way to learn how to build reports is by trying it out, and then spending time
fixing what inevitably starts out broken. This is the fun part (depending, I suppose, on
your idea of fun). I’m going to show you a few examples. For each, we will come up with
a recipe, involving the following steps:

1. Choose a template from the Report Library, as noted above. For the first
example, I want to make a list of patients for whom providers performed shared
decision-making for prostate cancer screening, as required by the CMS
Comprehensive Primary Care Initiative program (CPCI). So the template we will
use is “Find patients generic criteria,” because we’re looking for a list of
patients. Go to the Library tab, type “find patient” in the search box, make sure
“Show templates” is checked, then click the New Report button next to “Find
Patients – generic criteria”:

2. Set up the Criteria on the first tab of the Report Settings window that pops up:

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 When you run the report, it will use the From and To dates on top for any criteria in
the criteria list () prefixed by a clock. You can (and usually should) use relative rather
than absolute dates here, like M-3 to T to signify the last quarter, which is what CMS is
looking for in our case. That means whenever you run the report it will look at the last
quarter, relative to the date you ran it, instead of some quarter you originally defined
when you set up the report.

 The list of criteria here determines which patients Epic will pluck out of the database.
You check off the ones you’re going to use, and then put in the details of each criteria
on the right (at ). You can use the “Add” button to add additional criteria that aren’t
are available in the criteria list (at least in this template; simpler templates try to save
you from yourself by omitting this button). And you can define logical connections
between the criteria with the And, Or and Custom buttons below. Notice a bunch of the
criteria have clock icons, meaning they pay attention to the time interval specified at .

 Epic keeps a running summary of your report logic in this pane. Watch as we fill in
more criteria.

In this example, we’re going to change the Patient base from “My patients” to “Patients
seen in login department,” since that’s what CMS is interested in. (If you don’t see that
option, you chose the wrong template; “PHS Find patients - Generic criteria” doesn’t
have this; you need the “Find patient – generic criteria” template instead.) We’re going
to uncheck Patient living status, since it’s okay for this report to include patients who
have died since in the last quarter since they had a shared decision-making discussion.
We also will change the default time span on top from the last month to the last
quarter:

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How do we know we should change the Patient base from My patients to Patients seen
in login department? We can click the “Info” button on the upper right. It gives hints
like “My patients includes… all patients for whom you were an encounter or supervising
provider during the given date range, as well as any patients for whom you are currently
a member of the care team.”

So far, we’ve got a report which will list out all of the patients seen in the last quarter in
the login department. We want to limit it, however, to ones who had the CPCI-required
prostate cancer discussion. That gets stored in a SmartData element, which (in this
case) means a special SmartList where users type in a SmartPhrase
(.sdmprostatecancerscreening) and they get the following:

That SmartList has two choices—Agree and Decline screening, and whichever one gets
picked sticks a value (Yes or No, in this case) into a SmartData element, which is a piece

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 of structured data that can later be retrieved for reporting, like we’re doing now. This
Reference gets used in lots of instances, such as in Medicare Annual Wellness Visits, where you can
verify you screened for alcohol use with a SmartList. This action pigeonholes your
guide answer for later reporting to CMS.

SmartData are common enough to report on; you can type SmartData into the criteria
Reporting
search box on the upper left, and get a list of potential candidates:

SmartData come in several flavors, such as patient and encounter level. Patient level
means there’s one of this sort of element for the patient, and encounter means one per
encounter. This particular one is stored at the encounter level, since a patient could
agree to screening in one encounter, and decline the next time the topic comes up.

How do we tell if we’re using the right criterion out of several promising-looking
candidates? By trying it. Run the report, and if you know the patients are out there but
the report didn’t find any (or it found way too many), you’re likely doing it wrong and
you need to go back and refine the report.

Since we found a likely looking criteria for encounter-level SmartData, we’ll now set up
the details of the criteria:

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In this case, we need to tell Epic the specific SmartData element we’re going to use; I
typed in “prostate” to get a list of likely candidates. Then, there are a bunch of
“relationships” we can choose from. In this case, I don’t care if the answer was Yes or
No, so I didn’t choose “Equals Yes” or “Equals No”—I just put in Exists. If the encounter
element exists for this patient, include them in the report.

That’s it for choosing criteria for this report, but we’re not done yet.

3. Choose the Display elements for each patient. This occurs on the next tab,
labeled “Display.”

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In this case, for each patient who shows up in the report, I’m going to display
their MRN, name, DOB, age, sex and PCP. I could get greedy and add their
medications and last menstrual period, but it’s best to keep things simple, which
makes the report easier to read.
4. Next up, we’re going to head over to the Summary tab. We can use any of the
columns in the previous step to tally up numbers, and since we want to report
to CMS how many patients had each sort of shared decision-making discussion,
numbers will be helpful. There are lots of possible summaries. You’re going to
choose the right one for the job. For this report, a simple Summary table is
probably best:

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Reporting

There’s no obvious graphing that will be useful for this job, and we don’t have a
bunch of sub-categories to tabulate. (We might want to do all the CPCI reporting
in one report, which is possible in theory except that we’d need to define
specific SmartData columns in the display that aren’t yet available.)

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I want to group by PCP, and keep a total tally for each PCP, then a grand total
for the clinic (which is the login department, so other clinics could run the same
report without having to change the criteria). We’ll give the tab and the
summary logical names:

Then click on Groups to define how we’re grouping the summary. We’ll group
by PCP:

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Reporting

We don’t need to specify a label; Epic will use the column name by default.
Next, we need a summary function, and there a bunch to choose from:

Usually, you’ll want “Total count” if you’re simply tallying things, which we are.
In this case, we will do a total count by MRN’s (medical record numbers), so as
not to get bogus data if a lot of Roger Smith’s (or someone else with a common
name) talk about prostate cancer screening:

5. Lastly, in this example, we’ll save the report with a descriptive name (so we can
find it again in the future), using the General tab:

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Reporting

We press the Save button (you’d use Save As if you’re modifying an existing report
and saving it under a new name), then Run to try it out. Once it’s running, you’ll get
this window. Expect the report to take several minutes to run. Epic is looking at
every patient in the login department over the last quarter to see if this particular
piece of SmartData exists. That’s a lot to look at!

When the report is done running, you’ll get the results window, complete with the
details tab (detailing each patient) open first:

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Reporting

Our PCP tab totals participating patients by PCP:

Back in the My Reports tab, I’ll see a list of recently run reports, including this one:

If I’m going to use this report again, it makes sense to click the star icon (indicated by
the arrow) so the report can be accessed from the Favorite Reports pane up top. Once
you star the report, it will end up on the bottom of your favorite reports in the top pane.
You can then mouse over it to highlight the drag tool (the textured dots) on the left and
drag and drop it into a favorite folder:

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Reporting

You can also right click on the report to edit it (from the top pane, not the results pane
below). In this case, I’m going to add a Grouped Summary to get a Grand total (so we
don’t have to add up each PCP’s total).

I start off on the Summary tab, and click on Grouped Summary. (We’ll leave the previous
summary on the left alone. You can have multiple different summaries, each of which
will show up on their own tab.) Instead of having the Summary Display, Groups and
Functions panes in the Summary Table report described above, the Grouped Summary
uses “Previous” and “Next” icons on the bottom to navigate among the following
parameters:

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 • Summary display configures the title of the summary and a (typically shorter)
Reference name for the tab it appears on;
• The top grouping chooses one of the available columns (like PCP in this
guide example, since we’re going to group the total number of patients per PCP);
• Optional details, for example, if we wanted to show each patient who had the
Reporting shared decision-making conversation per PCP;
• Grand totals, which tots up the totals for whatever count we’re keeping for our
grouping. In this case, it will sum up all the total numbers for each PCP into a
grand total.

We’ll call this summary “Totals by PCP,” and call the tab name “Grand total”:

I click the “Next” icon to move to where we specify the top grouping, which will be total
per PCP:

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Reporting

We’ll summarize each PCP with a “Total count” for the Patient MRN column, giving us
the total number of individuals who had a prostate cancer screening shared decision-
making discussion per PCP this quarter. Note that if someone had the discussion twice,
they’ll be counted twice in this example. If you wanted to count each person only once,
you could use the “Count unique values” for the Patient MRN column.

Then, you can click “Next” twice (skipping over Details) or click on the “Grand Totals”
text to get a preview (on the left) of how the grand total will be displayed:

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I’m leaving out the Details since I don’t need to list every patient here (that’s already in
the first tab, Details). I Save and Run the report:

This gives a reasonable grand total. Whenever I want, I can run it again, by just going to
Epic > Reporting > My Reports and clicking on the CPC SDM Prostate cancer screening
report button. Since I used relative dates, we should get a report that looks at the last 3
months of data. I can always change the dates if I want a different slice of time, and I
don’t have to save this modified version of the report. Instead, we can just run it with
the new dates, leaving the original relative dates in for next time.

Second example: Morbid obesity in Medicare patients

My colleague Marc Carey requested a report of patients older than 65 with a BMI of 35,
broken down by department and PCP. This is another report for CPCI, CMS’s
Comprehensive Primary Care initiative, which will supplement reimbursement for
traditional Medicare patients with certain high risk problems, like obesity with
comorbidity.

1. Template. What are we looking for? Providers, orders? In this case, we’re again
looking for patients, so we’ll use the Find patients by Generic Criteria template
in the Report Library:

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2. Criteria. Marc asked for patients in multiple departments. One can choose a
patient base of “All patients,” which we will do, but this is asking for trouble
without further qualifiers, since it will look through the entire database in this
instance of Epic and potentially take hours to run. So I’m going to add another
criteria of Encounter department, and include our local CPCI clinics:

I will also stick with “Patient living status” alive, assuming we can’t be paid
incentives on patients who are dead (though there may be details involved
about when they died). And, happily, there’s a BMI criteria to select those who
exceed 35 kg/m2:

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Reporting

We can also consider putting in criteria for insurance, but this is tricky. There’s not just
one place in a patient record for “active insurance.” Patients can have primary,
secondary and tertiary coverages, worker’s comp visits. Coverages that vary from one
visit to the next. Even if we’re limiting to Medicare, Medicare comes in a lot of varieties
(Part A, Part B, and Part C for Medicare Advantage). Most end users, therefore, will need
help now and then finding criteria. It’s possible to add any field from one of Epic’s
databases as a criteria, and I found one called “EPT 5851-ADJUDICATION INFORMATION
- BENEFIT PACKAGE” which stores the electronically verified insurance that covers an
office visit.29 At our institution, it’s typically either something like “Commercial” for
commercial insurance, “Medicare Part B” for traditional Medicare, or “Medicare Benefit
Package” for Medicare Advantage. I added that with the “Add” button on top of the
criteria pane. Hence the following custom criteria:

29
If you’re wondering how I found the criteria: I search through a few patients’ EPT (Epic patient
database) records looking for all the places “Medicare” showed up.
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Note the logic: all of the Criteria on the left are AND’d together (patients have to be in
the appropriate departments, AND with a BMI ≥ 35, AND alive). For the specific
insurance package criteria, however, I indicated they could either have traditional OR
commercial Medicare (which is why the Or button is highlighted on the right).

3. Display. It would be sensible to put the BMI in the display listing the patients,
but there is no BMI column available. Still, there’s an Add button, so we can go
looking for one:

Searching for BMI in the resulting window, we get a bunch of possibilities—19,

in fact, most of which are wrong:

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You want to read the description of each candidate column to narrow down
your choices, then experiment. We don’t want a flowsheet value used in the ED
(the first possibility), the BMI from the sleep apnea questionnaire, or the BMI
percentile (used in pediatrics). But the third one, “Last BMI” looks promising, so
we’ll try that. By clicking on it, we make it available. In the pop-up window we
then highlight it and use the “Add >” button to actually display it:

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Reference And, by similar contrivance, and a lot of trial and error, I found that “Appt
payor” tells us what we want to know about insurance. “PCP Department” is
guide what we use when we mean the department of the PCP of the patient . (We
don’t want the last department they interacted with, like Gateway Lab or Call
Reporting Center.) So, our final Display columns are:

That yields the following report of Medicare patients, sortable by clicking on the column
headers, who have BMI’s ≥ 35.

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One could make a list of these patients using the “Add to list” button in the toolbar, or
go into each chart with the Chart button to change the Problem list diagnoses to what
CMS is expecting, for proper reimbursement.

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 Appendices
Appendices
Useful SmartLinks

Demographics
@NAME@ Patient’s name
@FNAME@ Patient’s first name
@MNAME@ Patient’s middle name or initial
@LNAME@ Patient’s last name
@PREFNAME@ Patient’s preferred name (e.g.,
nickname or preferred
transgender name)
@HE@ Patient’s subjective pronoun,
gender-adjusted (e.g., “he” or
“she”)
@HIS@ Patient’s possessive pronoun,
gender-adjusted (e.g., “his” or
“hers”)
@HIM@ Patient’s objective pronoun
@M@ Mr or Ms
@ME@ The name of the current Epic
user
@AGE@ Patient’s age
@AGEPEDS@ Patient’s age, with months for
kids and hours for newborns
@BDAY@ Patient’s birthday
@HMPH@ Home phone number
@WKPH@ Work phone number
@PH@ Home and work numbers
@MOB@ Mobile phone number
@PAYOR@ Insurance information for
current visit
@PREFPHARMACY@ Patient’s preferred pharmacy
@SUBNUM@ Insurance ID number

History
@PMH@ Past medical history
@PNMH@ Past medical history, pertinent negatives
@PROB@ Problem list
@PROBL@ Problem list, with details, including resolved problems
@PROBSPEC@ Specialty-specific problems
@HPROBL@ Hospital problems
 @SURGICALHX@, Past surgical history
@PSH@
@PNSH@ Past surgical history, pertinent negatives
Appendices @SOC@ Social history
@SOCH@ Social history, short form
Useful SmartLinks @SOCP@ Social history, pediatric form (excludes adult-oriented
information)
@SOCDOC@ Social history, narrative portion only
@FAMHX@ Family history
@OBHIST@ Obstetric history
@OBHISTORIG@ Obstetric history with more detail
@INFECTION@ Active infections (2016)

Medications
@MED@ Medications as of the beginning (i.e., preceding) the
current encounter, include sig, number dispensed and
refills
@CMED@ Medications, including any changes made during the
encounter (there’s also a non-tabular form,
@MEDSCURRENT@)
@MEDSDISCONTINUED@ Medications discontinued during this encounter
@MEDDISCHARGE@ For hospital and ambulatory encounters, medications
to be taken after discharge; will list changed and
unchanged medications
@MEDSTAKING@ Med listed as being taken by the patient from the
medication reconciliation activity; cf
@MEDSTAKINGNOTTAKING@
@REFILL@ Medications being re-ordered during the encounter
@ENCMEDSTART@ Medications as of the start of the encounter
(interprets discontinued meds more liberally than
@MED@)
@TAKEHOMEMEDS@ Medications started, stopped, and changed during
encounter
@TAKEHOMEMEDSSTART@ Medications started during encounter
@TAKEHOMEMEDSSTOP@ Medications stopped during encounter

Medication sublists (many of these have synonyms)

@MEDSABX@ Antibiotics on the current medication list
@MEDSACEARB@ Angiotensin inhibitors and receptor
blockers
@MEDSANTIANXIETY@ Anxiolytics
@MEDSANTICOAGULANTS@ Warfarin, heparin, and newer agents on
med list
219
 @MEDSANTIDIABETICS@ Medications intended to lower blood
sugar, including insulin and various oral
agents
Appendices @MEDSASPIRIN@ Aspirin and combinations
@MEDSBP@ Blood pressure agents (aka
Useful SmartLinks @MEDSHYPERTENSION@)
@MEDSDIURETICS@ Blood pressure agents of the diuretic
persuasion
@MEDSHIV@ HIV agents
@MEDSHYPNOTICS@ Soporifics
@MEDSNARCOTICS@ Opioids and opiates
@MEDSOSTEOPOROSIS@ Anti-resorptive agents
@MEDSPROTONPUMPINHIBITORS@ Guess
@MEDSPSYCH@ Medications commonly thought of as
primarily psychiatric in nature, including
antidepressants, stimulants,
antipsychotics, mood stabilizers, and
anxiety agents
@MEDSSTATINS@ Statins

Note sectioning SmartLinks

@ASSESSMENTTEXT@ Pulls in notes from the Assessment section of a progress
note. (Use @ASSESSMENTNOHEADERBEGIN@ and
@ASSESSMENTEND@ to delimit the assessment section
in your note template.)
@PLANTEXT@ Pulls in notes from the Plan section of a progress note.
(Use @PLANNOHEADERBEGIN@ and @PLANEND@ to
delimit the assessment section in your note template.)
@SUBJECTIVETEXT@ Pulls in notes from the Subjective section of a progress
note. (Use @SUBJECTIVENOHEADERBEGIN@ and
@SUBJECTIVEEND@ to delimit the assessment section in
your note template.)
@OBJECTIVETEXT@ Pulls in notes from the Objective section of a progress
note. (Use @OBJNOHEADERBEGIN@ and
@OBJECTIVEEND@ to delimit the assessment section in
your note template.)
@PTINSTRUCTBEGIN@ Typically used for inpatient Problem-oriented chartings;
and this lets you (for example) set aside a portion of a system-
@PTINSTRUCTEND@ defined Problem-oriented charting note where clinicians
can type instructions that go into the After visit summary.
Epic suggests adding a matching print group to the After
Visit Summary to include those instructions. This is
distinct from the @PATINSTR@ SmartLink, which copies

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 whatever is in the Patient instructions navigator section
to somewhere else, like the progress note.

Appendices

Useful SmartLinks Labs

@THISVISIT@ Results from current or most recent visit,
including any point of care tests
@LASTVISIT@ Results from the previous encounter
@LABBRIEF[basename:number@,... Labs, with time resulted but no reference
range
@LAB24@ Labs from the last 24 hours
@LASTLAB[basename:number@,... Labs, with each component in its own table,
and reference range displayed
@RESULTRCNT@ Most recent labs performed (you don’t need
to specify basenames, just a time scale, like
6w for 6 weeks or 12h for 12 hours
@GETLABS@ Similar to @RESULTRCNT@, but take a second
argument: blank means verbose with
comments, 1 includes ranges, status but no
comments, and 2 displays just name and
value, e.g., @GETLABS(6m,2)@
@LASTLABV@ Like RESULTRCNT, but also displays “final”
status, additional explanatory text, and can
accept lookback times with 6d, 3w, 4m, or 1y
(days, weeks, months and year) and an
optional argument after a comma—can be a
blank to display component name, value,
reference range, status and comments; 1 for
everything but the comments; and 2 for just
the name and value, e.g., .LASTLABV[6d,1
@GFRCG@ GFR via Cockcroft-Gault estimate
@IBRST@ In basket results. If you get to a lab letter from
the In Basket Letter button, @ibrst@ will
include all of the lab results from that In
basket message.

Logic
@CONDITIONALSMARTLINK@ Conditionally displays a SmartLink based on the
return value of another SmartLink. Pass an
input SmartLink, a comparison operator
(EQ, NEQ, GT, NGT, LT, NLT, CT, NCT), 1 if all
lines must be true (logical AND) or 0 if only
one line has to be true (logical OR), the
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 value to compare to, and an Output
SmartLink. This seems neat, but as of Epic
2017 has a lot of restrictions: it can only
Appendices pass back plain text SmartLinks of the type
SmartText (a SmartLink hooked up to a
Useful SmartLinks SmartText). The same restrictions apply to
its cousin @RULESMARTLINK@.

Measurements and vitals

@HCFA@ Head circumference for age
@LHCFA@ Last HCFA (as of most recently recorded HC)
@SFA@ Stature for age percentile (0-20 years)
@LSFA@ Last stature for age
@WFA@ Weight-for-age (0-20 years)
@LWFA@ Last WFA
@WFL@ Weight-for-length (0-36 months)
@WFS@ Weight-for-status (2-5 years)
@LBMIFA Last BMI-for-age percentile (2-20 years)
@LASTBP@ Last blood pressure taken (you need to specify a number)
@BPFA@ Pediatric blood pressure percentile for age
@BPFAW95@ Pediatric BP percentile with 95%ile threshold (to diagnose
hypertension)
@BPFAL@ Pediatric BP for age with lookback
@BSAE@ Body surface area, estimated
@BMIE@ BMI, estimated (if height/weight not entered in this
encounter, looks back to previous encounters)
@LASTBP@ Last blood pressure (you need to specify a lookback number,
like .LASTBP[3 to get the last 3 blood pressures)
@LASTHC@ Last head circumference (you need to specify a lookback
number, like .LASTHC[2 for last 2 head circumferences
@LASTHT@ Last height (you need to specify a number)
@LASTWT@ Last weight (you need to specify a number, like .LASTWT[4)
@LASTPULSE@ Last pulse readings (you need to specify a number,
like .LASTPULSE[4)
@LASTRESP@ Last respiratory rate (specify a number as above)
@LASTSPO2@ Last pulse ox (specify a number as above)
@LASTTEMP@ Last temperature reading (specify a number as above)
@LASTLMP@ Last menstrual period, specifying a lookback number
@LMP@ Just the last menstrual period
@VS@, Vital signs
@VITALS4M@
@V@ Vitals, one line variety
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 @MULTIPLEVITALS@ All vitals (not just the last ones) from this encounter

Appendices Obstetrics
EDD Estimated date of delivery of the current
Pregnancy episode
Useful SmartLinks
EDDANDMETHOD EDD and its basis
GA Gestational age (compared to @GAB@
which is the patient’s gestational age at
birth)
GP Gravida and Para from OB history
LMP Last menstrual period
LASTLMP Last several menstrual periods, like
@LASTLMP(3)@
MAMMOHX Family history of breast cancer
OBHIST Obstetric history
OBHISTORIG Another version of OB History

Health Maintenance
@HMDUE@ Health maintenance items that are due
@HMLIST@ Items on patient’s health maintenance list

Immunizations
@IMS@ Most recent immunizations (the last administered of each series)
@IMM@ Immunization history

Problem-oriented charting
@PROBAPNOTES@ Problem-oriented assessment and plans for this encounter
@PROBOVNOTES@ Problem overviews (not perfected as of 2/2013)
@LASTAPNOTES@ Last problem-oriented A&P’s documented, typically used for
inpatient
@CARECOORD@ Last Patient Care Coordination note

Provider information
@PCP@ Patient’s PCP
@ME@ Current Epic user
@MECREC@ Current user + credentials (like MD, DO or MA)
@PROVADDR@ Address of current provider
@PATIENTCARETEAM@ All providers listed as being on the care team
@CCLIST@ The list of recipients of a letter, along with addresses and
methods of delivery; see Communications Activity for
details and related SmartLinks

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 Spacetime phenomena
Appendices @TD@ Today’s date
@NOW@ Current time
@NEXTENCTHISDEPT@ Patient’s next appointment in the current department
Useful SmartLinks
@LASTENCTHISDEPT@ Last encounter this department
@AFUTAPPT@ All future appointments
@DATEFWD@ A future date calculator, adding a number of days from the
current day. You can either pass in an argument of days,
like .datefwd[7, or use a prebuilt version
like .datefwd84days. For example, to make a SmartPhrase
for progress notes outlining how you set up 3 narcotic
prescriptions, 1 per 28 days to last until 12 weeks from
now:
1 prescription each to last 28 days for today
(@TDNOREFRESH@), in 4 weeks
(@DATEFWD28DAYS@), and 8 weeks
(@DATEFWD56D@) . Next refill due in 12 weeks
(@DATEFWD84D@).

@DATEBACK@ Same as @datefwd@, but it subtracts a number of days

from the current day instead of adding them.

Note tools
@IMAGES@ Any Haiku/Canto pictures you took that are attached to this encounter

For even more SmartLinks, you can look at Epic’s official lists (the latest version I found
as of this writing is for Epic 2015). Not everything works in every context (some work
just in Letters, others just in Progress notes) and not all are active in every instance of
Epic. But it gives you an idea of possibilities.

To see which SmartLinks are available in your build, go to the SmartPhrase Butler in any
progress note:

SmartPhrase Butler icon (highlighted in yellow), Epic 2014

SmartPhrase Butler icon, Epic 2017

Or, just type “.?” in a progress note:

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Appendices

Useful SmartPhrases

Leave only the “SmartLinks” box checked, and search through the list to your heart’s
content. Not everything may work in your region, but it can’t hurt to try.

Useful SmartPhrases
Availability varies by institution. The following include items in the Providence Health &
Services Epic environments.

Differential diagnoses
SmartPhrase Contents
.ddxabdominalpain Abdominal pain differential diagnosis in
descending order of frequency
.ddxabnormaluterinebleeding Differential diagnosis for uterine bleeding

There are about 40 of these altogether; type .ddx in a progress note to bring up a list

Miscellany (Tips & Tricks)

What follows is a listing of items I find useful in day to day work, if not as fundamentally
important as what’s listed in the Strategy Guide.

Edit multiple orders

Sometimes you want to order, say, a bunch of labs, and they should all be for next year
before the patient comes in for a physical and not today. You don’t need to change the
Expected date individually. Tee up the orders in Meds & Orders (or the Visit taskbar in
Epic 2018), and before signing them, click on the Edit Multiple button:

Epic 2018 orders shopping cart, with its Edit Multiple button

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Epic 2017 Edit Multiple button in Meds & Orders

This option is also available in Order Entry on the upper right:

Pressing Edit Multiple will pop up this window:

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 Click on the Select All/Deselect All button, or use the individual checkboxes to
indicate which orders you want to apply changes to.

 Order Class: for labs, it will typically be Clinic Collect or Lab Collect. If you’re printing
orders for the patient to carry to an outside lab, you can use External.

 If you intend to change the labs to some distant date, select the Future button, which
then unveils the following additional options:

You could put in a specific date or a calculation like “m+3” in the expected field, and
“y+1” in the Expires field.

 Press Accept if you’re done, or Accept and Stay if you have one bunch of orders you
intended for lab collection 3 months from now, and another bunch clinic collect for
today.

Place an order as another user

Sometimes you are covering for another provider, and you need to order a study but
you want the results to go to the PCP, and not you. That’s what the Providers button in
the Visit taskbar’s orders shopping cart and in Meds & Orders can be used for:

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“Providers” button on top of the Options menu of Epic 2018’s orders shopping cart

Providers button in Meds & Orders in Epic 2017

This same function is available in an obscure fashion by clicking on the name of the
ordering provider in Order Entry (or the Providers button on top):

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Click there, and you’ll get the following dialog box:

You can change the name of the Authorizing Provider, which is how Epic thinks of the
mastermind behind an order—the person truly responsible for it, and to whom results
would go. You will still be recorded as the Ordering provider in case there’s any need for
breaking kneecaps.

Keeping track of families

If you practice primary care, there’s a good chance you care for multiple members of the
same family. Knowing names of parents and children can help you cajole family
members to come in for appropriate care without seeming like you’re an idiot.

Epic has a couple of ways of tracking family members. For clinicians, I’d use the History
activity (or navigator section):

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You can enter in the names as you enter in family history:

I type in the first and last names so I can copy and paste them into a patient search
(pressing alt-P as needed to restrict the search to patients for whom I’m the PCP). This
makes it easier to immunize a whole family during flu season.

More keyboard shortcuts

In Windows applications, you’ll often note underlined characters in button labels or
menu entries:

These tell you a keyboard shortcut is available. If you’re hands are already on the
keyboard, don’t futz with the mouse. Instead, in this examples, you can type Alt-l to
clear your entries, Alt-s to Accept and Stay, Alt-a to accept, or Alt-c to cancel. (If you’re
using a Mac keyboard, depending on how you set up your Citrix application, you might
type either Opt-a or -a here.)

Finding your own patients

When using a patient lookup box, you can check the “My patients” box to quickly find
your own patients, even if you can’t quite remember their name:

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As above, the shortcut is Alt-p to click this box. That way, even if you only remember
their first name, like “Ivanka” you can type it. Click the “Use sounds-like” box if you’re
not sure of the spelling.

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