Epic
This standard keyboard shortcut—or typing a period followed by a short abbreviation—instantly pulls pre-written text templates, progress notes, or discharge instructions directly into a note.
What is a Dotphrase (or SmartPhrase)?
Subjective information is what the patient tells you, while this category includes measurable facts obtained by the clinical team, such as vital signs, physical exam findings, and lab results.
What is Objective data (or the "O" in SOAP)?
This common 2-letter abbreviation stands for the primary reason the patient came to the clinic or emergency room today.
What is CC (Chief Complaint)?
Instead of writing "high blood pressure" in the chart, a scribe documents this term.
What is Hypertension (HTN)?
Show us how to follow up on a suspect.
*Give Demonstration* (PLY)
You need to check the patient's past labs, previous clinic visits, and external hospital records. You would open this central hub in Epic to view their entire historical medical record.
What is Chart Review?
While the HPI captures the narrative of the chief complaint, this systematic "head-to-toe" checklist of symptoms captures any additional subjective complaints the patient may be experiencing today.
What is the Review of Systems (ROS)?
When documenting past surgical history, "CABG" (pronounced "cabbage") stands for this major cardiac procedure.
What is Coronary Artery Bypass Graft?
The medical term for a fast heart rate exceeding 100 beats per minute in an adult.
What is Tachycardia?
Show us how to FULLY reject a suspect.
*Give Demonstration* (PLY)
When documenting the physical exam or ROS, hitting this single keyboard button lets you jump seamlessly from one wild-card bracket [***] or drop-down field to the next without touching your mouse.
What is F2?
Criteria for compliant Chief Complaints
- What is follow up on conditions and/or symptoms written in the patient's perspective?
The abbreviation "GERD" stands for this common gastrointestinal condition causing heartburn.
What is Gastroesophageal Reflux Disease?
The clinical term for difficulty swallowing.
What is Dysphagia?
Show us how to add / remove suspects from a patient's problem list.
*Give Demonstration* (PLY)
Typing this common Dotphrase into your note automatically imports the patient's current blood pressure, heart rate, temperature, and pulse oximetry.
What is .vitals?
What is "drug therapy"?
In the Assessment & Plan, "p.o." means the medication should be taken this way, while "n.p.o." means this restriction.
What is by mouth (per os) and nothing by mouth (nil per os)?
The suffix "-itis" means inflammation; appending it to the liver yields this medical condition.
What is Hepatitis?
Show us how to get to the CDR worklist and filter for our providers.
*Give Demonstration*
Typing this two-character symbol sequence into any SmartPhrase or text field allows you to drop in real-time patient data, such as .age, .name, or .vitals,
What are SmartLinks?
Dictate an adequate assessment for Hypertensive heart and kidney disease with chronic kidney disease stage 3B and other heart failure.
Answers may vary. Should include complete MEAT for each.
When documenting an elderly patient's kidney function labs, a provider requests an "eGFR." This acronym stands for this clinical marker.
What is Estimated Glomerular Filtration Rate?
While evaluating an elderly patient with balance issues or peripheral neuropathy, the provider notes a lack of muscle coordination when the patient attempts voluntary movements like walking or reaching. You document this specific medical term in the neurological exam.
What is Ataxia?
Show us how to complete a Weekly Planning summary.
*Give Demonstration* (PLY)