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| Questão | Responda |
| You want to Time Mark the new progress notes for your patient, but not the new initial assessment or consult notes. Can you do that? | No. Clicking Time Mark automatically marks ALL notes as no longer new. You cannot individually Time Mark notes. |
| Which type of orders don’t get released? | Orders that are saved (pended) and not signed (as well as Signed and Held orders, until they are manually released.) |
| True or False? Time Mark means that you have actually read all of the notes in the patient’s chart. | False. Time Mark serves as a bookmark and organization tool for you. It simply marks the notes as no longer new. |
| What should you click to authorize but not release orders? | Sign and Hold |
| Time Mark | tells the system “DON’T ALERT ME” unless there are new notes written from this point forward. |
| File Time | represents the time the user clicked Sign and saved the note to the patient’s chart. |
| When the surgeon logs in, what is the first Startup Activity? | Provider’s schedule |
| Note Time | represents the time the note was started or the time that was entered in the Note Time field when documenting the note. |
| Filtering vs. sorting in NOTES | Use filter to view notes written by a particular type of author. Use Columns to sort by type of note written |
| Does a surgeon have to open a patient’s chart to review information? | No. Use the reports at the bottom of the screen. |
| File Time vs. Note Time | File Time represents the time the user clicked Sign and saved the note to the patient’s chart. Note Time represents the time the note was started or the time that was entered in the Note Time field when documenting the note. |
| How do you open a patient’s chart? | Double-click the patient. |
| In which activity can you view accordion reports? | Patient Summary activity. |
| How can you tell that there is an abnormal value within a specified time interval in accordion reports? | Red ! |
| How is an abnormal value denoted in accordion reports? | RED text |
| How can you tell if there are values hidden within a time interval in accordion reports? | + sign |
| After opening the patient’s chart,another tab appears at the top of the screen. What do we call each of those tabs? | Workspaces |
| On the Add or Remove Buttons from Toolbar window, what is the difference between the Reports and Display Name columns? | In the Reports column, you enter the name of the report you want to have as a shortcut on the Reports toolbar. The name in the Display Name column is what you actually see on a report’s button in Patient Summary. |
| Accordion report | Accordion reports are used to review information on patients with large amounts of data |
| Intake/Output activity | The Intake and Output activity is great for reviewing the patient’s fluid levels and hydration. |
| True or False? A physician can see all notes from multiple encounters in the Notes activity. | False. The Notes activity only shows notes from the current admission. |
| Synopsis | Provides an at-a-glance overview of the patient’s vitals and events that have occurred throughout the hospitalization |
| How do I get rid of the New Notes icon? | Time Mark button |
| What can you do with this unfinished order? | Pend the order by clicking Save Work. |
| What must you do before that unfinished order can be acted upon? | Complete and sign the order. |
| EnRol stands for... | Enhanced record lookup |
| What’s the definition of Time Mark? | Marks all notes as no longer new to me. |
| What happens behind the scenes when you modify the frequency of a medication order? | The original order is discontinued and a new order is entered. As a result, two rows appear on the MAR for nurses. |
| What happens behind the scenes when you modify the rate of a medication? | The original order is just modified. As a result only one row appears on the MAR for nurses. |
| Does it say that I’ve read them all? | NO |
| 3 ways for MD to locate orders quickly | EnRol Synonyms Preference List |
| Where should you look for past lab results on a patient who has just been admitted? | Results Review because it shows you all results from prior to this admission. |
| What does the pushpin mean if it is next to a problem in the problem list? | The pushpin indicates that the problem is a chronic problem (an ongoing problem for the patient). |
| Where do I look for vitals and lab results for a patient who has been hospitalized for a while? | Accordion reports in Patient Summary |
| What is the Principal problem? | The Principal problem is the main reason for the patient’s hospitalization. |
| What is an accordion report used for? | Reviewing lots of data; good for ICU patients. Use to see trends. |
| When documenting with a positive/negative button in the NoteWriter, how can you quickly indicate that the specific condition is present or positive? | Left-click or click the plus sign. |
| When reviewing information in an accordion, what do the columns represent? | Time intervals |
| When documenting with a positive/negative button, how can you quickly indicate that the specific condition is absent or negative? | Right-click or click the minus sign. |
| What does a plus sign mean when it appears next to a value in an accordion report? | There are additional values documented within that time interval. |
| When documenting with a positive/negative button, how can you quickly add a comment? | Hover your mouse cursor over the positive/negative button and start typing. Or, double click the positive/negative button to open the comments window and then start typing. |
| What does an exclamation point mean when it appears next to a value in an accordion report? | There is an abnormal value documented within that time interval. |
| How can you tell if a comment has already been added to a positive/negative button? | The positive/negative button is underlined |
| What point and click tool makes writing a progress notes easier? | NoteWriter |
| True or False? You can add free text to a note in the Note form. | True. You can add additional information to your note by using SmartPhrases or free text in the white space within the note. |
| True or False? You can add free text to a note in the Note form. | True. You can add additional information to your note by using SmartPhrases or free text in the white space within the note. |
| How do I indicate a pertinent positive or present condition? | Click the + sign in the positive/negative button or left-click the positive/negative button. |
| Macro | a predefined set of values that can be pulled into a note with a click of a button, simply by creating and enabling the macro appropriate for each patient. |
| How do I indicate a negative or absent condition? | Click the minus (–) sign in the positive/negative button or right-click the positive/negative button. |
| What is a My List? | A list of patients that I am caring during my shift. I control the columns, the default report, and I manage the list of patients. |
| What is a system list, and how can it be used to organize patients? | A list of patients that is automatically updated by the system. You can make a shortcut to these lists in a My List. |
| How do I include a comment on the positive/negative button? | Hover the mouse over the positive/negative button and begin typing or double-click to open the comments field. |
| How do you add yourself to the treatment team for a patient? | Find the patient on the unit-based System List. Right-click on the patient’s name and select Assign Me. |
| You need to save a draft of the note before signing it. What should you do? | Pend the note. |
| How do you remove yourself from the treatment team for a patient? | Find the patient in the My Patients lists. Right-click on the patient’s name and select End My Assignment. |
| How can you search for a patient that is not admitted to the hospital? | Click Patient Lookup to search through the entire database of patients, including those who are not admitted. |
| How can pended notes be finished? | Open the Notes activity or notes section of a navigator, select the note from the Incomplete tab and click Edit (or double-click the note), and edit it. Click Sign to file when it’s complete. |
| What activity should you use to get report at start of shift? | Patient Summary activity |
| Where is the most efficient place for a physician to see a list of all active orders for a patient? | Active tab in the Orders activity |
| When writing a sticky note, what should you include at the end? | Your name and the date you are writing the note. |
| How do I change the frequency of a medication? | Click Modify and then click Change Frequency. After that use the frequency buttons or the Selection button to select a new frequency for the order. |
| Patient Summary report is | an activity offers you an at-a-glance reference to the most important medical details about a patient. |
| Acknowledge orders means... | It means that you have seen the order and you believe it meets safety standards and is appropriate for the patient. |
| What does modifying the frequency actually do to the original order? | Discontinues the original order and places a new order |
| Do both the discontinued and new order then show up on the MAR? | Yes—The discontinued order appears in yellow in the Discontinued section of the MAR, and the current order appears in its own row. |
| The purpose of the sticky note communication | you want to leave a note |
| How do I change the End Time of a medication? | Click Modify and then click Change End Time. After that, enter the new end date/time in the appropriate fields. |
| True or False? When you log out, the system remembers all filters and views that you set on the Work List | False. The Work List only saves the last view selected by the user. The filter is not saved. |
| What does changing the End Time of an order do to the original order? | It simply modifies the original order. It does not discontinue the original order and put a new order in the system. As a result only one row appears on the MAR for orders that have a changed end time. |
| How would you change the Work List to display only medication tasks organized by patient? | Change to Patient View and filter on Medications |
| what two other changes to orders can you make without the system discontinuing the original order and placing a brand new order? | Change the rate of an order or change the administration instructions |
| True or False? The Work List only allows a nurse to view tasks for one patient at a time. | False. If the nurse selects a list of patients and clicks Work List, tasks for all patients on that list appear in the Work List to review. |
| A physician is searching for an order and cannot find it. She knows she typed the order correctly and has been able to find the order in the past. What might the physician need to do to find the order? | Search the Facility List. |
| For what time frame does the Work List display tasks when first opened? | Current Shift |
| True or False? The Work List includes all tasks that a nurse might have to complete throughout a shift. | False. There are things a nurse is responsible for that are not listed as discrete tasks on the Work List. |
| A physician types “walk” in the search field and an order for Ambulate Patient appears. Why? | Walk is a synonym for Ambulate Patient. |
| True or False? When you log out, the system remembers all filters and views that you set on the Work List. | False. The Work List only saves the last view selected by the user. The filter is not saved. |
| When searching for new orders, the clinician only types the first few letters and presses ENTER. This is called searching using | EnRol, which is Epic’s completion matching (Enhanced Record Lookup). |
| How would you change the Work List to display only medication tasks organized by patient? | Change to Patient View and filter on Medications |
| True or False? The Work List only allows a nurse to view tasks for one patient at a time. | False. If the nurse selects a list of patients and clicks Work List, tasks for all patients on that list appear in the Work List to review. |
| true or false If an attending physician Time Marks the notes for a patient, the notes are marked as no longer new for all the clinicians on the patient’s treatment team. | FALSE TIME MARK IS A PERSONAL BOOKMARK |
| For what time frame does the Work List display tasks when first opened? | Current Shift |
| True or False? When the rate of a medication order is modified, the system just changes the original order. | TRUE |
| True or False? The Work List includes all tasks that a nurse might have to complete throughout a shift. | False. There are things a nurse is responsible for that are not listed as discrete tasks on the Work List. |
| What are three search tools physicians can use to help them find new orders in the Orders activity? | EnRol, synonyms, preference list |
| True or False? An order that needs a cosignature is not active and cannot be acted upon until the order is cosigned. | FALSE |
| List at least three pieces of information that can be found in the Details report within the Doc Flowsheets activity. | The value, comments, time taken, time recorded, user taken, user recorded, show audit. |
| True or False? The system automatically saves the filter that is currently applied when you exit the Work List. | FALSE |
| What color are the values prior to filing them to a patient’s chart? What color are the values after they are filed? | Values are PINK prior to being filed. Values are BLACK after being filed. |
| True or False? If a nurse hasn’t documented a scheduled med as given within one hour, the due time automatically gets marked as Not Given | TRUE |
| True or False? If a clinician closes a patient’s chart without clicking File in the Doc Flowsheets activity, any unfiled data in the flowsheet is lost. | False. The system automatically files any pending data when the end user changes flowsheet templates, leaves the Doc Flowsheets activity, closes the patient’s chart, or logs out. |
| True or False? Documenting a patient’s vital signs in the Admission Navigator also updates the Doc Flowsheets activity in Hyperspace. | TRUE |
| While reconciling prior-to-admission medications, the physician notices the shopping cart has a red header. What does the physician need to do to get the shopping cart header to be green? | Reconcile all of the orders to turn green |
| If a clinician enters WDL in the “Within Defined Limits” row for a system, what does this mean? | “WDL” means that all values taken within that system fall within the defined range. No other data needs to be entered. |
| True or False? Epic does not have an audit trail for values in Doc Flowsheets that have been edited or deleted. | False. Epic does have an audit trail for edited or deleted data, and any values that have been edited or deleted are flagged. |
| What are two ways that templates can be added to the Care Plan? | Best practice, manually added |
| How does a nurse document that all values are normal except for a few? | Enter an “X” in the WDL row. (This documents that all values are within defined limits, except...) Then enter the abnormal information in the appropriate rows. |
| What are two ways the Patient Education record can be started? | Care plan interventions and manually added |
| Where can a nurse look to find information on the “defined” values for a given row? | A nurse can view the Row Information in the Details report on the right side of the screen. This gives him information about normal values, possible choices, and the last filed data. |
| When a nurse goes into a flowsheet and wants to enter new values, what should be done before documenting any information to ensure the data is entered under the correct date and time?The nurse should click the Add Col button or the New hyperlink. This drops a new column with the current date and time. If charting values taken in the past, the Insert Col button should be used. | The nurse should click the Add Col button or the New hyperlink. This drops a new column with the current date and time. If charting values taken in the past, the Insert Col button should be used. |
| True or False? A nurse should always write down where she left off in her flowsheet documentation when she goes to another activity, closes the patient’s chart, or logs out and she would like to resume documenting where she left off. | False. A nurse can tell where she last documented on each flowsheet template by the bookmark in the template’s table of contents. If she clicks Jump to where I left off, the system jumps straight to the cell under the last one she documented in. |
| In the Problem List section of the navigator, how can you mark a problem as the principal problem? | You select the check box in the Principal column after indicating that the problem is a hospital problem. |
| What is a SmartText and how can it be pulled in to a note? | A SmartText is a template for writing a note. It can be pulled in from the Insert SmartText field. |
| Embedded within a SmartText are SmartLists. How can you start filling out a SmartList? Make a selection? Accept your selection? | To start filling out a SmartList using the keyboard, press F2. To make a selection, use the SPACEBAR. To accept your selection, press ENTER. |
| To start filling out a SmartList using the mouse... | use the Next Field option (under the All Other Tools menu). To make a selection, left-click, and to accept your selection, right-click. |
| True or False? A note can be signed even if all of the SmartLists have not been completed. | False. All SmartLists and wildcards must be completed before the note can be signed. |
| What the purpose of a wildcard? | A wildcard, denoted by ***, is intended to provide the clinician with a place to enter free text. |
| True or False? When creating a User SmartPhrase that includes a SmartText, a physician should insert the SmartText into the note before clicking the green plus sign. | False. If you are creating a User SmartPhrase that contains a SmartText, click the green plus sign first. Then, pull your SmartText in to your note window. This prevents any patient-specific information from being saved in your template. |
| After creating a User SmartPhrase that includes a SmartText using the green plus sign, how can you pull the new text into a note to use it for patient documentation? | You have created a SmartPhrase, so you can summon it into your note by typing a ‘dot’ and the SmartPhrase name or by clicking the List My Phrases (.my?) button. |
| After filing a note to the patient’s chart, where in Hyperspace can that note be read? | The note can be viewed from the Notes activity or an encounter report in Chart Review. |
| How do you add yourself to a patient’s treatment team? | Find the patient on your My Unit My List. Right-click and select Assign Me. |
| A patient is being transferred to a new unit and you are no longer going to be caring for that patient. What should you do? | Remove yourself from treatment team. |
| How can you remove yourself from the treatment team? | Select the patient. Right-click and select End My Assignment |
| If a patient who appears in a unit system list shortcut embedded in a My List is discharged, is he gone from the My List? | Yes. Patients are automatically removed from unit system lists after they are discharged. |
| How can you finish documentation on a patient who has been discharged. | From Patient Lists, look up the patient in the Search field and select “4Day Discharged” from the drop down list |
| After updating your patient assignments, which activity should you use when getting report? | Patient Summary (specifically, the SBAR Handoff report) |
| While reviewing reports in Patient Summary, you find a report that you really like but it’s not on your report toolbar. What can you do? | Add it as a button. |
| How do you add new report buttons to the toolbar? | Click the wrench. |
| During your review, you also see orders that need to be acknowledged. What does it mean to acknowledge an order? | Sign off on the order. Indicate you saw the order. |
| After getting report and acknowledging new orders, you want to begin prioritizing tasks. Which activity can you use to help you with this? | Work List |
| Upon opening the Work list from Patient Lists, you want to see a list of all tasks for all the patients you’ve been assigned, and you want these tasks to appear in chronological order. What should you do? | Change the view to Time View. |
| Now that the tasks are listed chronologically, you want to only see tasks related to medications. How can you do that? | Apply a filter to only show medication-related tasks. |
| After changing the view and applying the filter, you close the Work List. The next time you open the Work List, what will be saved? | The view only. Views are saved, but filters are not. |
| How can you document giving a scheduled medication? | Click the due time, confirm that what appears in the Time field is the time you gave the med, and document a MAR action of Given or New Bag (depending on the medication). |
| When giving a PRN medication, where can you see the last administration time for this medication? | In the Recent Administrations section in the expanded details for the medication or on the MAR Report |
| How do you document giving a PRN medication? | Click in the cell for the current time, confirm that what appears in the Time field is the time you are giving the med, and document a MAR action of Given or New Bag (depending on the medication). |
| If you give a medication over an hour after its original due time, how should you document this? | Document the original due time as Not Given, and then click in the cell for the time you gave the medication, and document an action of Given or New Bag (depending on the medication). |
| If a medication is given late and subsequent doses should be rescheduled, what should the nurse do? | Reschedule the next dose, and then send a message to pharmacy to request they reschedule the remaining doses. |
| Where do nurses go in Epic to document vitals and assessments? | Doc Flowsheets |
| Inside of a flowsheet template, there are: | Groups |
| Groups contain: | Rows—what you document on |
| What tool should you use to see the possible choices for each row and document? | Details report which is docked on the right side of the Doc Flowsheets activity |
| How can you quickly document in a multi-select row within the Details report? | Phrase to help you remember this: “Left-click to pick; Right-click to stick.” |
| What does Charting to a Definition mean? | Charting only those entries that do not fall within the defined limits (WDL) |
| Is Charting to a Definition something Epic created? | No, but Epic supports it with cascading flowsheets. |
| Do you need to document in every single row that is in the flowsheet template? | No. Not all rows are applicable for every patient. Only document in rows that are relevant for the patient. |
| When documenting in Doc Flowsheets, you need a column for the current time. How can you quickly add it? | Click Add Column. |
| What if you are back documenting? Then what should you click to get a column for the time the assessment was actually performed? | Click Insert Column. |
| While doing your documentation, you accidentally enter the wrong value in a row. How can you fix it? | Click in the cell and change the value. |
| Is there an audit trail for data edited prior to filing? | No. An audit trail only appears if filed data is edited |
| Where do I go to review a patient’s prior encounters? | Chart Review. |
| While completing admission documentation, you confirm with the patient that his allergies and history are up to date. What should you do before moving on to indicate you spoke to the patient and the information is accurate? | Click Mark as Reviewed to put a date and time stamp in this section. |
| What does Mark as Reviewed mean? | I talked to the patient and verified the information is up to date. |
| On the patient’s Problem List, what do you call the main reason for the admission? | Principal Problem |
| What do you call other problems that might affect care during this admission? | Hospital Problems |
| What status/field allows you to indicate that the patient presented to the hospital with that problem? | Present on Admission |
| SmartText is... | a template for writing a note. Summoned into the note by searching for a template in the Insert SmartText field. |
| What does a SmartLink do? | It pulls information from patient’s chart (built only by Epic). Summoned into a note by typing a period “.” followed by the SmartLink abbreviation |
| A SmartPhrase is .. | predefined words or block of words; summoned into a note by typing a period “.” followed by the SmartPhrase abbreviation. |
| Wildcard: *** = | free text field |
| What is the first step in completing Admission Med Rec when admitting a patient from the ED? | Review the list of current orders and decide which to continue upon admission |
| While reviewing the list of current orders, how can the physician tell if he has reviewed all the orders? | The header in the shopping cart on the right side of the screen turns green and says “All orders reviewed.” |
| What’s the difference between clicking Don’t Order and Discontinue for a Home medication? | Don’t Order means that the medication is not ordered for the admission but might be resumed upon discharge.• Discontinue means that the medication is completely canceled. |
| What’s the difference between clicking Don’t Order and Discontinue for a Home medication? | Don’t Order means that the medication is not ordered for the admission but might be resumed upon discharge.• Discontinue means that the medication is completely canceled. |
| What is one reason an Order Set might appear as a suggestion for the physician? | Diagnosis/Problem List, Favorites, BPAs |
| What do I click to change the details of the order? | Summary Sentence (blue hyperlink) or the name of the order |
| After queuing up all the orders needed for an admission from the ED, what do you need to do? | Click Sign & Hold - Will Be Initiated by Receiving Unit. |
| Click Sign & Hold -Are those orders active immediately? | No. They are signed and held until the nurse on the receiving unit releases them |
| How do a patient’s Care Plan and Patient Education record get started? | Care Plan: BPAs and manually clicking Apply Template Patient Education: Care Plan goals or interventions and manually clicking Add Title. |
| When documenting that you taught the patient a number of teaching points at the same time, what can you click to document most efficiently? | Multiple button |
| What does a green check mean in Patient Education? | You’ve reviewed with the patient and they understand. The education is complete |
| In the Care Plan activity, how can you document the problem is no longer an issue? | Resolve the problem. |
| Who is the authorizing provider? | Anyone with the authority to sign an order is eligible to be an authorizing provider. |
| Who is the ordering provider? | Whoever decided to place the order. The provider who initiates the order |
| Is it possible that the ordering provider isn’t the attending provider? | Yes (for example, resident/physician assistant) |
| What does Epic call the first screen a user sees when they log in? | Startup activity |
| Whose name appears in the Entered by field? | The person who is logged in to the system at the time the order is being entered |
| How can a surgeon quickly sort their list of patients by unit? | Click the Unit column in Patient Lists on the right of the screen |
| What type of information can a surgeon gather from reports at the bottom of the startup activities? | Vitals, I/O, Current Meds, and more |
| What types of orders require a cosign? | Verbal—usually placed over the phone with readback. Some Protocol orders—orders that nurses can place without actually hearing from the physician. Standard orders such as starting an IV line. |
| How can a clinician open a patient’s chart also called patient workspace? | Select patient and double-click |
| Who will cosign the order? | The authorizing provider. |
| What are the tabs along the left of the screen in a patient’s chart called? | Activities |
| How do you know which notes are new? | the Clock icon appears next to the note |
| How can you quickly find a patient’s H&P within the Notes activity? | Click the H&P tab to see only H&Ps. Or, from the All Notes tab, click the Type column header to sort by note type. |
| Where can the ordering provider cosign orders? | 3 places: In Basket, Orders Activity, Admission and Transfer Navigators |
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