Show:
Chapter 11 Documenting Vitals and Assessments
Chapter 12
Physician Admission from ED - Documentation
Chapter 13
Physician Admission from ED - Admission Orders
Chapter 14
Nurse Admission from ED
Chapter 15
Documenting Patient Education
100
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 BLUE prior to being filed. Values are BLACK after being filed.
100
In the Problem List section of the navigator, how can you mark a problem as the principal problem? What must this problem be marked as first?
You select the check box in the Principal column after indicating that the problem is a hospital problem.
100
In what section of the medication reconciliation navigator do you decide whether a PTA med should be ordered for this hospitalization?
In the Reconcile PTA section, you determine whether the medication should be Ordered, Not Ordered, Replaced, or Discontinued.
100
What does it mean to release signed and held orders?
Releasing orders means you are making them active. Other clinicians will be notified of the orders and can start acting on them.
100
True or False? Teaching points are always be attached to a teaching topic.
False. A teaching point can be added to a topic or directly to a title. The topic just serves as an organizer for multiple points.
200
True or False? If an end user 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.
200
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.
200
How can you quickly indicate the patient’s last dose of all of the PTA medications was today?
Click Mark Unselected Today in the Review PTA Medications section of the navigator.
200
True or False? Documenting the patient’s vitals in the navigator will also populate the Vital Signs flowsheet template in the Doc Flowsheets activity.
True. All documentation that you complete in a navigator will automatically populate the appropriate places throughout the patient’s chart.
200
On which tab can you document progress of education provided to the patient?
The Unresolved Education tab.
300
If a provider enters WDL in the “Within Defined Limits” row of 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.
300
True or False? A note can be accepted and filed to the patient’s chart even if all of the SmartLists have not been completed.
False. All SmartLists and wildcards must be completed before the note will be accepted and filed to the patient’s record.
300
What are two reasons an Order Set is suggested in the New Orders for Floor section?
Based on a diagnosis listed in the patient’s Problem List, based on a BestPractice Advisory, or based on the type of navigator
300
What are two ways templates can be added to the Care Plan activity?
Care Plan templates can be added automatically by accepting a recommendation in a BestPractice Advisory or they can be added manually by clicking Apply Template.
300
How can you tell when a teaching point has been completed?
A green check mark appears next to it.
400
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.
400
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 My SmartPhrase and modifying 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.
400
What does it mean to Sign & Hold an order?
It means that the order has been authorized, but it is not released or active yet.
400
What are two ways patient education titles can be added to the Patient Education activity?
Patient Education titles can be added automatically if a Care Plan goal or intervention requires teaching, or they can be added manually by clicking Add Title.
400
How can you most efficiently document several teaching points to several learners?
Click Multiple when documenting on multiple learners or multiple points at the same time.
500
List at least three pieces of information that can be found in the Docked Details report within the Doc Flowsheets activity.
The value, comments, time taken, time recorded, user taken, user recorded, show audit.
500
After creating a User SmartPhrase that includes a SmartText using the green plus sign, how can you pull the modified text into a note to use it for patient documentation?
You have created a SmartPhrase, so you can summon this into your note by typing a ‘dot’ and the SmartPhrase name or by clicking the List My Phrases (.my?) button.
500
What should you type in the search field if the patient tells you they are taking a medication but they do not know the medication name?
Type “Help” in the search field to add “unknown to patient” to the med list. You might need to click the Database Lookup tab to find it.
500
Before a nurse releases signed and held orders for a new patient who just arrived on the floor from the ED, what other step needs to be done first? What will happen if this step is not done?
Before releasing signed and held orders, the patient’s arrival on the unit must be confirmed in Epic using the Unit Census activity. If this is not done, the system will think the patient is still in their original unit and orders might be affected (medications might be dispensed to the wrong place, etc).
500
What should you do when all of the teaching points for a topic are complete?
Resolve the Topic.