Navigating the intricate labyrinth of Epic can be daunting, but mastering the art of creating new notes is essential for effective documentation and seamless communication within the healthcare ecosystem. Embark on this comprehensive guide and unveil the secrets to crafting impeccable notes that convey your clinical insights with clarity and precision, leaving an indelible mark on patient care.
To initiate the process, navigate to the “New Note” button, a beacon beckoning you to capture your observations and contribute to the tapestry of the patient’s medical history. With a blank canvas before you, conjure a title that succinctly encapsulates the essence of the note, guiding the reader’s attention to its core purpose. Next, select the appropriate note type from the myriad options available, ensuring it aligns seamlessly with the content you intend to convey. Whether crafting a progress note to chronicle the patient’s journey or an admission note to establish a solid foundation for their care, meticulous selection of the note type will pave the way for effective communication.
With the groundwork laid, embark on the enriching journey of penning your note. Begin with a captivating opener that entices the reader to delve into the depths of your clinical expertise. Utilize vivid language and specific details to paint a multifaceted picture of the patient’s condition, capturing their unique presentation and the intricacies of their health status. Interweave pertinent past medical history, weaving a cohesive narrative that contextualizes the patient’s current situation and provides a solid foundation for understanding their healthcare trajectory. As you progress through the note, seamlessly incorporate essential components such as physical examination findings, diagnostic test results, and treatment plans, ensuring a comprehensive overview of the patient’s care.
Accessing the New Note Feature
Epic’s comprehensive electronic health record (EHR) system provides robust functionality for healthcare providers to efficiently document and manage patient care. Among its many capabilities, Epic offers a versatile “New Note” feature that allows users to quickly create and customize patient notes, enhancing the accuracy and efficiency of documentation.
Navigating to the New Note interface is a straightforward process, accessible through various methods. One common approach is to utilize the “Quick Note” button located within the patient chart. By hovering over the patient’s name in the patient list, a drop-down menu appears, presenting the “Quick Note” option. Alternatively, users can access the New Note interface directly from the patient’s EHR. Within the patient chart, look for the “Documents” tab and select “New Note” from the drop-down menu.
Upon selecting the “New Note” option, a new window or tab will open, displaying the New Note interface. This interface consists of several sections, each designed to facilitate specific aspects of note creation. The main text editor occupies a prominent position, providing a dedicated space for entering clinical notes. Above the text editor, a toolbar offers quick access to commonly used formatting options such as bold, italics, and bullet points, enabling users to effortlessly enhance the presentation of their notes.
Adjacent to the main text editor, a collapsible sidebar provides additional functionality. The sidebar comprises several tabs, including “Templates,” “SmartPhrases,” and “Orders.” The “Templates” tab offers pre-defined note templates that can be customized and reused, saving time and ensuring consistency in documentation. The “SmartPhrases” tab provides a library of commonly used phrases and macros that can be easily inserted into the note, further streamlining the documentation process.
The “Orders” tab within the sidebar allows users to seamlessly integrate medication orders, laboratory tests, and other interventions directly into the patient note. This seamless integration enhances efficiency by reducing the need to navigate between different sections of the EHR to complete documentation tasks.
Options for Customizing New Notes
Epic’s New Note feature empowers users to personalize their documentation workflow through a range of customization options. These options can be tailored to individual preferences or specific clinical scenarios, ensuring optimal efficiency and accuracy.
Selecting Note Types
Epic offers a diverse selection of note types to accommodate the varied documentation requirements of different healthcare settings. These note types are designed to provide structured templates and predefined content, streamlining documentation and ensuring consistency. Users can choose from a wide range of note types, such as progress notes, discharge summaries, operative reports, and consultation notes, among others.
Utilizing Customizable Templates
Epic’s New Note feature provides the flexibility to create, customize, and use note templates. These templates can be tailored to specific clinical domains, such as cardiology, oncology, or pediatrics. By utilizing templates, users can streamline the documentation process, ensuring consistency and completeness in their notes.
Incorporating SmartPhrases
Epic’s extensive library of SmartPhrases enables users to insert frequently used phrases and macros into their notes with a simple click. This feature expedites documentation, reducing the need for repetitive typing and minimizing the risk of errors. SmartPhrases can be customized and organized into categories, allowing users to quickly access the most relevant phrases for their specific documentation needs.
Integrating Orders and Results
The New Note interface seamlessly integrates with Epic’s robust order entry and results reporting systems. This integration allows users to incorporate orders, laboratory results, and other relevant clinical information directly into their notes. By eliminating the need to navigate between different sections of the EHR, this integration enhances efficiency and reduces the risk of errors.
Personalizing the Interface
Epic’s New Note interface can be personalized to match individual preferences and workflow requirements. Users can customize the layout of the interface, including the location of toolbars, sidebars, and other elements. Additionally, users can create and save custom views, allowing them to quickly access frequently used tools and information.
Security and Confidentiality
Epic prioritizes the security and confidentiality of patient information. The New Note interface incorporates robust security measures to protect patient data from unauthorized access and breaches. Access to patient notes is restricted based on user permissions, ensuring that only authorized healthcare providers can view and edit patient information. Additionally, Epic’s audit trails provide a comprehensive record of all actions performed within the EHR, including the creation and modification of notes.
Entering the Note’s Subject
To begin creating a new note in Epic, you’ll first need to provide a subject. This subject will help you and others quickly identify the purpose and content of the note. To enter the subject, follow these detailed steps:
- Click on the “New Note” button: Locate the “New Note” button, typically found in the upper-right corner of the Epic user interface. Click on this button to initiate the note creation process.
- Choose the appropriate note type: A dropdown menu will appear, presenting you with various note types. Select the note type that best aligns with the purpose and content of the note you wish to create. For instance, if the note pertains to a specific patient’s encounter, choose the “Encounter Note” option.
- Enter the subject: In the “Subject” field, type in a concise and descriptive subject for your note. This subject should clearly indicate the key topic or focus of the note. Use specific keywords that highlight the note’s purpose. For example, instead of using a generic subject like “Patient Update,” consider using a subject like “Hypertension Management for Patient X.”
- Avoid using abbreviations or medical jargon: The subject should be easily understandable to anyone who reads the note, including non-medical personnel.
- Consider using keywords for searchability: If you anticipate that you or others may need to search for this note later, include relevant keywords in the subject.
li>Keep the subject concise: Aim for a subject length of around 5-15 words. This ensures that the subject is easily readable and informative.
- Click “OK” to finalize the subject: Once you have entered the desired subject, click on the “OK” button. This will finalize the subject and take you to the note editor, where you can proceed with writing the content of your note.
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Typing directly into the note
You can simply start typing your note directly into the body of the note. This is the most straightforward way to add content, and it allows you to quickly and easily get your thoughts down.
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Pasting text from another source
If you have text that you have already written or copied from another source, you can paste it into the note. To do this, simply copy the text, then click on the “Paste” button in the note toolbar.
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Inserting images or files
You can also insert images or files into the note. To do this, click on the “Insert” button in the note toolbar, then select the type of file you want to insert. You can insert images from your computer, from a URL, or from a cloud storage service.
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Creating a table
If you need to create a table in your note, click on the “Table” button in the note toolbar. This will insert a table with a default number of rows and columns. You can then add or delete rows and columns as needed.
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Headings
You can create headings in your note to help organize your content. To do this, simply click on the “Heading” button in the note toolbar, then select the level of heading you want to create.
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Lists
You can create lists in your note to help organize your content. To do this, simply click on the “List” button in the note toolbar, then select the type of list you want to create.
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Links
You can create links in your note to link to other websites or resources. To do this, simply highlight the text you want to link, then click on the “Link” button in the note toolbar. You can then enter the URL of the website or resource you want to link to.
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Notes
You can create notes in your note to add additional information or comments. To do this, simply click on the “Note” button in the note toolbar. This will insert a note into your note. You can then type your note into the note field.
- Check the content of the note. Make sure that all of the necessary information is included and that it is accurate.
- Check the formatting of the note. Make sure that the text is formatted correctly and that the layout is easy to read.
- Check the attachments. Make sure that all of the attachments are included and that they are in the correct format.
- Check the comments. Make sure that all of the comments are included and that they are relevant to the note.
- Make sure that you have a pop-up blocker installed. If you have a pop-up blocker installed, it may be blocking the preview window from opening.
- Try refreshing the page. If the preview window does not open, try refreshing the page.
- Contact your system administrator. If you are still having trouble previewing the note, contact your system administrator for help.
- Open Link in New Tab: Check the “Open Link in New Tab” box to open the linked website in a new browser tab.
- Set Page Title: In the “Page Title” field, enter a title for the linked webpage. This title will appear when you hover over the link.
- Add Target: In the “Target” field, specify a target for the link. The default target is “_self,” which opens the link in the same window. You can also use “_blank” to open the link in a new window.
- Add Class: In the “Class” field, enter a CSS class to apply to the link. This allows you to customize the appearance of the link using CSS.
- Use descriptive text: The displayed text of the link should clearly indicate where it leads. Avoid using generic terms like “Click here.”
- Test links regularly: Ensure that your hyperlinks are working correctly by testing them regularly.
- Consider accessibility: Ensure that your hyperlinks are accessible to users with disabilities by providing alternative text (alt text) where appropriate.
- Click the “New Note” button on the patient’s chart.
- In the “Note Type” field, select the template you want to use.
- Click the “Create” button.
- Go to the “Administration” tab.
- Click on “Templates” in the left-hand navigation menu.
- Click on the “Note Templates” tab.
- Select the template you want to customize and click on the “Edit” button.
- Place the cursor in the location where you want to insert the SmartText.
- Type the SmartText code. For example, to insert the patient’s name, type %NAME%. SmartText codes are case-insensitive.
- Press the “Enter” key.
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Access Configuration Menu: Click on the "Configure" tab situated at the top of the Epic interface.
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Select "Notes": Locate and click on the "Notes" option from the left-hand menu.
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Note Default Settings: The "Note Default Settings" panel will appear on the right-hand side.
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Note Title: Specify the default prefix or suffix that will be automatically added to new note titles.
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Note Type: Select the default note type for new notes (e.g., Progress Note, Assessment Note).
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Template: Choose a default template that will be used for new notes.
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Assigned User: Designate a default user to whom new notes will be assigned.
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Expiration Date: Set a default expiration date for new notes.
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Display Name: Determine the default display name for the user who created the note.
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Display Options: Configure how notes are displayed (e.g., font size, note width).
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Text Color: Choose default text colors for various note sections (e.g., headers, body text).
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Paragraph Indentation: Set the default indentation for paragraphs within notes.
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Signature Line: Customize the default signature line that appears at the end of notes.
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Font: Select the default font and font size for note content.
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Access Note Types: Navigate to "Configure" > "Notes" > "Note Types."
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Create New Note Type: Click on the "Create" button to initiate the creation process.
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Note Type Name: Provide a meaningful name for the new note type.
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Note Template: Choose a template that will be associated with this note type.
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Default Settings: Specify default settings for the new note type, including visibility, accessibility, and retention period.
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Access Control: Define permissions to control who can access and view notes.
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Permission Groups: Create permission groups to manage note access for specific user roles.
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Note Authorization: Limit access to sensitive note content by requiring authorization from designated users.
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Activity Log: Maintain an audit trail of note access and modifications to ensure accountability.
- Routine
- Urgent
- High
- Critical
- Stat
- Open the note you want to link the document to.
- Click on the “Document” tab at the top of the note.
- Click on the “Select File” button and browse to the document you want to link.
- Click on the “Upload” button.
- Highlight the text you want to link.
- Click on the “Link” button located in the toolbar at the top of the note.
- Enter the Note ID or search for the note you want to link to.
- Select the “Note” tab.
- Click on the “Link” button next to the desired note.
- Highlight the text you want to link.
- Click on the “Link” button located in the toolbar at the top of the note.
- Select the “Document” tab.
- Choose the document you want to link to.
- Click on the “Link” button.
- Highlight the text you want to link.
- Click on the “Link” button located in the toolbar at the top of the note.
- Select the “External” tab.
- Enter the URL of the external resource.
- Click on the “Link” button.
- Click on the “Linked Notes” tab at the top of a note to view a list of all notes linked to that note.
- Click on the “Document” tab at the top of a note to view a list of all documents linked to that note.
- Click on any hyperlink within a note to open the linked note, document, or external resource.
- Unlinking Notes: To unlink a note, open the “Linked Notes” tab of the main note and click on the “Unlink” button next to the note you want to remove.
- Unlinking Documents: To unlink a document, open the “Document” tab of the main note and click on the “Remove” button next to the document you want to remove.
- Editing Hyperlinks: To edit a hyperlink, highlight the linked text and click on the “Link” button located in the toolbar at the top of the note. Make any necessary changes to the link and click on the “Update” button.
- Removing Hyperlinks: To remove a hyperlink, highlight the linked text and click on the “Link” button located in the toolbar at the top of the note. Click on the “Unlink” button to remove the link.
- Improved organization and structure of patient information
- Enhanced collaboration by allowing multiple users to access and contribute to the same body of information
- Streamlined documentation and reduced duplication of effort
- Facilitated access to relevant patient information and resources
- Increased efficiency and productivity in patient care
- Open the patient’s medical record and navigate to the desired note.
- Click on the “Image” icon located in the toolbar at the top of the note.
- Select the “Insert Image” option from the drop-down menu.
- In the “Insert Image” dialog box, click on the “Browse” button.
- Locate and select the image file you want to insert.
- Click on the “Open” button to upload the image into the note.
- Click on the image to select it. Handles will appear around the image.
- Drag and drop the image to the desired location in the note.
- To resize the image, click on a handle and drag it inwards or outwards.
- Click on the image to select it.
- A floating toolbar will appear above the image with options to rotate, crop, and delete the image.
- Click on the image to select it.
- Select the “Annotations” tab from the floating toolbar above the image.
- Choose the desired annotation type (e.g., arrow, line, circle) and click on the image to place the annotation.
- Enter any necessary text or notes into the annotation box that appears.
- Click on the “Image” icon in the toolbar.
- Select the “Insert Image from URL” option.
- Enter the URL of the external image and click on the “Insert” button.
- Click on the “Table” icon in the toolbar.
- Select the desired number of columns and rows for the table.
- Click on a cell in the table and insert an image using the “Insert Image” option.
- Use images to enhance the visual appeal of notes.
- Be selective in choosing images to avoid overwhelming the reader.
- Ensure that images are relevant to the content of the note.
- Consider the privacy and confidentiality of images before inserting them.
- Click on the “Note Templates” tab in the left sidebar.
- Click on the “New Note Template” button.
- Enter a name for the template.
- Select the type of note you want to create (e.g., Progress Note, Discharge Summary).
- Click on the “Create” button.
- Click on the “Note Templates” tab in the left sidebar.
- Find the template you want to edit and click on it.
- Make your changes to the template.
- Click on the “Save” button.
- Click on the “New Note” button in the left sidebar.
- Select the type of note you want to create (e.g., Progress Note, Discharge Summary).
- Click on the “Use Template” button.
- Select the template you want to use.
- Click on the “Create” button.
- Text Editor: Use the text editor to add and format text, insert images, and create tables.
- SmartPhrases: Use SmartPhrases to insert commonly used phrases and templates.
- Macros: Use macros to insert dynamic data, such as patient demographics and medical history.
- Signatures: Use signatures to add your electronic signature to the note.
- Customize your templates: Tailor your templates to your specific needs and preferences.
- Use macros and SmartPhrases: Macros and SmartPhrases can save you time and improve the quality of your notes.
- Review your templates regularly: Make sure your templates are up-to-date and reflect your current practice.
- Share your templates with colleagues: Sharing templates can help to improve consistency and quality across your team.
- Open the patient’s chart.
- Click on the “Notes” tab.
- Click on the “New Note” button.
- Enter the title and body of the note.
- Click on the “Assign To” button.
- Select the patient or group of patients to whom you want to assign the note.
- Click on the “OK” button.
- Click on the “Patient List” icon in the Epic toolbar.
- Select the group of patients to whom you want to assign the note.
- Click on the “Notes” tab.
- Click on the “New Note” button.
- Enter the title and body of the note.
- Click on the “Assign To” button.
- Select the group of patients to whom you want to assign the note.
- Click on the “OK” button.
- Open the patient’s chart.
- Click on the “Notes” tab.
- Click on the “New Note” button.
- Select a template from the list of available templates.
- Enter the title and body of the note.
- Click on the “Assign To” button.
- Select the patient to whom you want to assign the note.
- Click on the “OK” button.
- Click on the “Patient List” icon in the Epic toolbar.
- Select the group of patients to whom you want to assign the note.
- Click on the “Notes” tab.
- Click on the “New Note” button.
- Select a template from the list of available templates.
- Enter the title and body of the note.
- Click on the “Assign To” button.
- Select the group of patients to whom you want to assign the note.
- Click on the “OK” button.
- Open the Chart tab.
- Click the Notes tab.
- Click the New Note button.
- In the Note Type field, select the type of note you want to create.
- In the Title field, enter a title for the note.
- In the Body field, enter the text of the note.
- Click the Save button.
- Progress notes
- Consultation notes
- Operative notes
- Procedure notes
- Discharge notes
| Subject Example | Explanation |
|---|---|
| Hypertension Management for Patient X |
Clear and concise: Indicates the specific purpose of the note (hypertension management) and the patient it pertains to (Patient X). |
| Patient Update |
Generic and ambiguous: Provides no specific information about the content of the note or the patient it relates to. |
| Hypertension: Medications and Lifestyle Changes |
Use of keywords: Includes keywords like “hypertension,” “medications,” and “lifestyle changes” for increased searchability. |
Adding Body Content to the Note
Once you have created a new note, you can begin adding content to it. There are several ways to do this, including:
In addition to these basic content types, you can also add other elements to your notes, such as:
By using these different content types, you can create notes that are both informative and organized. You can also use notes to share your thoughts and ideas with others.
151 How To Make New Note In Epic
Epic is a widely used electronic health record (EHR) system in healthcare organizations. It provides a comprehensive platform for managing patient information, including medical history, medications, allergies, and progress notes.
Creating new notes in Epic is a crucial task for healthcare professionals to document patient encounters, track progress, and communicate with other team members. This guide will provide a step-by-step process on how to create new notes in Epic, including specifying the note’s author.
Specifying the Note’s Author
When creating a new note in Epic, it is essential to specify the author of the note. The author is the healthcare professional who is responsible for the content of the note and can be a physician, nurse, or other authorized personnel. Here’s how to specify the note’s author:
1. Open the New Note Window
To create a new note, begin by clicking on the “New Note” button within the patient’s chart. This will launch the New Note window.
2. Select the Note Type
In the New Note window, you will need to select the type of note you want to create. Epic offers various note types, such as Progress Notes, Consult Notes, and Discharge Summaries. Choose the appropriate note type based on the purpose of your documentation.
3. Enter the Note Title
Once you have selected the note type, enter a descriptive title for your note. The title should provide a brief summary of the note’s content, making it easy to identify later.
4. Click on the “Author” Field
In the New Note window, locate the “Author” field. This field will display the name of the currently logged-in user who is creating the note. If you need to change the author, click on the “Author” field.
5. Search for the Author
A pop-up window will appear, allowing you to search for the desired author. You can enter the author’s name, employee ID, or any other identifying information in the search bar. A list of matching authors will be displayed.
If the author you are looking for is not listed, you may need to contact your Epic system administrator to grant them appropriate access to create notes.
6. Select the Author
Once you have found the desired author, click on their name to select them. The selected author’s name will be displayed in the “Author” field of the New Note window.
7. Verify the Author
Before saving the note, it is important to verify that the correct author has been selected. The author’s name should appear in the “Author” field, along with their title and credentials.
8. Save the Note
Once you have specified the note’s author and completed the note’s content, click on the “Save” button to save the note. The note will be added to the patient’s chart under the specified note type.
| Step | Action |
|---|---|
| 1 | Open the New Note window. |
| 2 | Select the note type. |
| 3 | Enter the note title. |
| 4 | Click on the “Author” field. |
| 5 | Search for the author. |
| 6 | Select the author. |
| 7 | Verify the author. |
| 8 | Save the note. |
Previewing the Note before Saving
After you have entered all the necessary information into the note, you can preview it before saving it to make sure that it is complete and accurate.
To preview the note, click on the “Preview” button in the toolbar. This will open a new window that displays a preview of the note. The preview will show you the note’s content, as well as any attachments or comments that have been added.
You can use the preview to make any necessary changes to the note before saving it. For example, you can add or remove text, change the formatting, or add attachments.
Once you are satisfied with the preview, click on the “Save” button to save the note.
Tips for Previewing the Note
Here are a few tips for previewing the note before saving it:
Troubleshooting Note Preview
If you are having trouble previewing the note, here are a few things you can try:
| Steps for Preview | Action |
|---|---|
| 1. Click on “Add New Note” under the Chart tab. | Initiate note creation process. |
| 2. Choose a note type from the drop-down list. | Select the type of note to create (e.g., Progress Note, Discharge Summary). |
| 3. Complete the note fields with relevant information. | Enter details including the patient’s history, assessment, plan, and other pertinent data. |
| 4. Click on the “Preview” button in the toolbar. | Display a preview of the note before saving. |
By thoroughly previewing your note before saving, you can ensure its completeness, accuracy, and compliance with relevant standards, enhancing the quality of patient care and minimizing the risk of errors or omissions.
Adding Tables to the Note
Tables are a great way to organize information in a note. You can use them to create a list of items, track data over time, or display complex relationships. To add a table to a note, follow these steps:
1. Click on the “Insert” tab in the toolbar.
2. Select “Table” from the menu.
3. Drag your cursor over the grid to select the number of rows and columns you want.
4. Release the mouse button to create the table.
You can now enter data into the table by clicking on a cell and typing. To format the table, right-click on a cell and select “Table Properties” from the menu. In the Table Properties dialog box, you can change the border color, cell padding, and cell spacing. You can also merge and split cells.
5. To add a row to the table, click on the “Insert” tab in the toolbar and select “Insert Row Above” or “Insert Row Below.”
6. To add a column to the table, click on the “Insert” tab in the toolbar and select “Insert Column Left” or “Insert Column Right.”
7. To delete a row or column, right-click on the row or column and select “Delete” from the menu.
8. To merge two or more cells, select the cells and right-click. Select “Merge Cells” from the menu.
9. To split a cell into two or more cells, right-click on the cell and select “Split Cells” from the menu.
10. To resize a row or column, drag the border of the row or column to the desired size.
Here is a table example that you can use to track your progress on a project:
| Task | Start Date | End Date | Status |
|---|---|---|---|
| Write proposal | 2023-03-01 | 2023-03-15 | In progress |
| Gather data | 2023-03-16 | 2023-03-31 | Not started |
| Analyze data | 2023-04-01 | 2023-04-15 | Not started |
| Write report | 2023-04-16 | 2023-04-30 | Not started |
Adding Hyperlinks to the Note
To add hyperlinks to your Epic note, follow these steps:
Step 1: Highlight the Text
Highlight the text you want to link by clicking and dragging your mouse over it.
Step 2: Click the “A” (Anchor) Icon
In the Epic note editor toolbar, click the “A” (anchor) icon.
Step 3: Enter the Link URL
In the “Link URL” field of the pop-up window, enter the web address (URL) you want to link to.
Step 4: Customize Link Display (Optional)
You can customize the appearance of the link by entering text in the “Display Text” field. This text will appear instead of the URL. By default, the actual URL will be displayed.
Step 5: Click “OK”
Click the “OK” button to create the hyperlink.
Additional Options for Hyperlinks
In addition to the basic steps above, you can also use the following options to further customize your hyperlinks:
Best Practices for Using Hyperlinks
When using hyperlinks in Epic notes, consider the following best practices:
Using Templates for Notes
Epic provides a variety of note templates that can be used to create structured notes that meet specific requirements. Templates can be created and customized by administrators, and they can be used by clinicians to quickly and easily create notes that are consistent and complete.
Creating a New Note Using a Template
Customizing Note Templates
Administrators can customize note templates to meet the specific needs of their organization. This includes adding or removing fields, changing the order of fields, and setting default values. To customize a note template:
Using SmartText in Note Templates
SmartText is a feature that allows you to insert commonly used text and phrases into notes with a few keystrokes. SmartText can be used to insert patient demographics, medications, allergies, and other information. To use SmartText in a note template:
SmartText Codes
The following table lists some common SmartText codes:
| Code | Description |
|---|---|
| %NAME% | Patient’s name |
| %DOB% | Patient’s date of birth |
| %MRN% | Patient’s medical record number |
| %MEDICATIONS% | List of patient’s medications |
| %ALLERGIES% | List of patient’s allergies |
Setting Note Defaults
To modify the default settings for new notes, navigate to the “Configure” tab within the Epic system.
Step-by-Step Instructions
Customizable Default Settings
The following fields can be customized to establish default settings for new notes:
Configure additional default settings tailored to your specific requirements.
Advanced Note Defaults
Beyond the basic settings, you can further customize note defaults by tailoring the following attributes:
By adjusting these advanced settings, you can create note defaults that align precisely with your institution’s preferences and workflow.
Creating a Default Note Type
You can define a custom default note type by following these steps:
Once you have created a custom note type, you can set it as the default for new notes in the “Note Default Settings” panel.
Default Note Security
Ensure appropriate security measures are in place by configuring note-level permissions through the “Security” tab within the Epic system.
By implementing robust security measures, you can safeguard the confidentiality and integrity of patient information contained within notes.
Setting Note Priorities
Notes in Epic can be assigned different priority levels to indicate their urgency and importance. Here’s a detailed guide on how to set note priorities:
1. Open the Note Editor
Begin by opening the note you wish to assign a priority to. If the note is new, click on the “New Note” button in the patient’s chart.
2. Access the Priority Drop-down Menu
In the note editor, locate the “Priority” drop-down menu. It’s typically displayed in the upper-right corner of the screen.
3. Select a Priority Level
Click on the drop-down arrow to reveal the list of available priority levels. Epic offers a range of options, including:
4. Consider the Note’s Significance
When selecting a priority level, consider the importance and urgency of the information contained in the note. Here’s a breakdown of each priority level:
| Priority Level | Description |
|---|---|
| Routine | Non-urgent information that can be addressed during regular clinic hours. |
| Urgent | Information that requires attention but can wait until the next clinic visit. |
| High | Important information that needs to be addressed as soon as possible. |
| Critical | Information that requires immediate action and may impact the patient’s safety. |
| Stat | Information that requires immediate attention and urgent intervention. |
5. Save the Note
Once you have assigned the appropriate priority level, save the note by clicking on the “Save” button. The priority level will be recorded and displayed in the list of notes in the patient’s chart.
6. Considerations for Urgent and Critical Notes
For notes with high priority levels, such as “Urgent” or “Critical,” it’s essential to provide a clear and concise summary of the situation in the first sentence. This summary should include any relevant patient information, such as vital signs, symptoms, and medications.
7. Communication with Other Team Members
If the note contains information that requires immediate attention from other team members, consider using the “Flag” feature. This will send an electronic notification to the designated individuals, ensuring that the message is received and acted upon promptly.
8. Modifying Note Priorities Later
Note priorities can be modified later if necessary. Simply open the note again, access the “Priority” drop-down menu, and select the new priority level.
9. Using the “High Priority Filter”
Epic provides a “High Priority Filter” that allows users to quickly identify notes with “High,” “Critical,” or “Stat” priority levels. This filter can be accessed from the “Notes” tab in the patient’s chart.
10. Importance of Accurate Priority Setting
Assigning accurate priority levels to notes helps ensure that urgent and critical information is addressed promptly. It also streamlines communication among healthcare team members, facilitating efficient patient care.
Linking Notes Together
Within Epic, you can link notes together to establish relationships and facilitate cross-referencing. This feature allows you to create a network of interconnected notes, providing a comprehensive view of patient information and enabling seamless navigation.
To link notes together:
1. Open the first note you want to link.
2. Click on the “Link” button located in the toolbar at the top of the note.
3. Enter the Note ID or search for the note you want to link to.
4. Click on the “Link” button next to the desired note.
The two notes will now be linked together. You can view the linked notes by clicking on the “Linked Notes” tab at the top of the note.
Linking Multiple Notes
You can link multiple notes together by following the steps outlined above for each note. Each linked note will be added to the “Linked Notes” tab of the main note.
Linking Notes to Documents
In addition to linking notes to other notes, you can also link them to documents. This is useful for attaching relevant documents, such as images, PDFs, or lab results, to a specific note.
To link a note to a document:
The document will now be linked to the note and will be accessible from the “Document” tab.
Utilizing Hyperlinks
Hyperlinks can be used to create dynamic links within notes and to external resources. This provides a quick and convenient way to access additional information.
Creating Hyperlinks to Other Notes
To create a hyperlink to another note:
Creating Hyperlinks to Documents
To create a hyperlink to a document:
Creating Hyperlinks to External Resources
To create a hyperlink to an external resource, such as a website or PDF:
Navigating Linked Notes and Documents
You can easily navigate between linked notes and documents using the following methods:
Managing Linked Notes and Documents
You can manage linked notes and documents in the following ways:
Benefits of Linking Notes and Documents
Linking notes and documents provides several benefits, including:
Best Practices for Linking Notes and Documents
To maximize the benefits of linking notes and documents, it’s important to follow these best practices:
| Best Practice | Rationale |
|---|---|
| Use descriptive link text | Identifies the purpose of the link clearly |
| Avoid linking to notes or documents that are not relevant | Keeps the network of linked notes and documents manageable and organized |
| Review and update links regularly | Ensures that links remain accurate and relevant over time |
| Use hyperlinks sparingly | Prevents overloading notes with unnecessary links and improves readability |
| Consider using a note template or note type | Provides a structured approach to linking notes and documents, ensuring consistency and organization |
Inserting Images into Notes
Epic allows users to insert images into notes to enhance the visual appeal and convey information more effectively. This feature is particularly useful for displaying charts, graphs, screenshots, or clinical images. Here’s a step-by-step guide on how to insert images into notes in Epic:
Positioning the Image
Once the image is inserted, you can adjust its position within the note:
Editing the Image
Epic provides basic editing options for images:
Adding Image Annotations
You can add annotations to images to highlight specific areas or provide additional information:
Embedding External Images
You can also embed external images from a URL into notes:
Creating Image Tables
For displaying multiple images side-by-side, you can create an image table:
Image Size and File Format
Epic recommends using image files with a maximum size of 5 MB. Supported image formats include: JPG, JPEG, PNG, GIF, and BMP.
Additional Tips
Adding Hyperlinks to Notes
Links can be inserted into notes. Text destined to be converted into a link should be highlighted by first clicking and dragging the mouse to select it. When the mouse button is released, many options will appear – one of which is the hyperlink button, which resembles two linked chain links. Clicking this button will summon the “Edit Hyperlink” dialog box. Enter the URL of the page to which you want to make the link in the “URL” field. The Target Frame drop down list can be used to control which page the link opens in – select the notes box option to make the link open in the current window.
Keyboard Shortcut: Ctrl + K
Adding Hyperlinks to External Websites
If an external website is to be linked to, the URL must start with “http://” or “https://”. The Edit Hyperlink dialog box has a “Test Link” button that can be used to check if the URL is valid and opens the correct page. Should the link be invalid, an error message will be shown.
The “Edit Hyperlink” dialog box also provides options for setting a tooltip that will appear when the mouse hovers over the link, and for setting a target frame.
Adding Hyperlinks to Epic Pages
A hyperlink to an Epic page can be created by prepending the name of the page with “^”. For example, to link to the “Inpatient” note, use the following URL:
^Inpatient
The target frame option can be used to control which page the link opens in. The default behavior is to open the link in a small note window within the active application. To make the link open in a new tab in the web browser, select the “Epic Web” option from the “Target Frame” drop down list.
Link Colors and Display
Epic uses the following colors for hyperlinks:
| Link Status | Color |
|---|---|
| Unvisited | Blue |
| Visited | Purple |
| Active | Red |
Hyperlinks are displayed underlined by default. If the “Underline” option in the “Edit Hyperlink” dialog box is unchecked, the link will not be underlined.
Removing Hyperlinks
To remove a hyperlink, select the text of the link and click the “Clear Hyperlink” button in the hyperlink menu. The hyperlink will be removed, and the text will return to its normal color.
Keyboard Shortcut: Ctrl + Shift + K
Using Templates for Notes
Epic allows you to create and use templates for notes. This can save you time by providing a pre-defined structure and content for your notes.
1. Create a New Note Template
To create a new note template, follow these steps:
2. Edit a Note Template
To edit a note template, follow these steps:
3. Use a Note Template
To use a note template, follow these steps:
4. Add and Edit Content in a Note Template
You can add and edit content in a note template by using the following tools:
5. Sections of a Note Template
A note template can be divided into the following sections:
| Section | Description |
|---|---|
| Header | Contains the patient’s name, medical record number, and other identifying information. |
| Subjective | Contains the patient’s history of present illness. |
| Objective | Contains the results of the physical exam, laboratory tests, and other objective findings. |
| Assessment | Contains the clinician’s assessment of the patient’s condition. |
| Plan | Contains the clinician’s plan for the patient’s care. |
6. Tips for Using Note Templates
Here are some tips for using note templates:
Assigning Notes to Patients
In Epic, notes can be assigned to individual patients or to a group of patients. To assign a note to a patient:
The assigned note will now appear in the patient’s chart under the “Notes” tab.
Assigning Notes to a Group of Patients
To assign a note to a group of patients, you can use the “Patient List” tool. To do this:
The assigned note will now appear in the charts of all patients in the selected group under the “Notes” tab.
Assigning Notes to a Patient Using a Template
You can also use a template to assign a note to a patient. To do this:
The assigned note will now appear in the patient’s chart under the “Notes” tab.
Assigning Notes to a Group of Patients Using a Template
To assign a note to a group of patients using a template:
The assigned note will now appear in the charts of all patients in the selected group under the “Notes” tab.
How To Make New Note In Epic
To make a new note in Epic, follow these steps:
People Also Ask About
1. How do I add a note to a patient’s chart in Epic?
To add a note to a patient’s chart in Epic, follow the steps outlined above.
2. What are the different types of notes that I can create in Epic?
You can create the following types of notes in Epic:
3. How do I search for a note in Epic?
To search for a note in Epic, click the Search button in the Notes tab.
