list-of-helpful-epic-smartlinks-for-providers
– hopefully this will be useful to nurses, providers, and other Epic users to help with patient care.
MC EPIC Template
END OF SHIFT RN REPORT
ATT: @ATTPROV@
PCP: @PCP@
@NAME@ @AGE@(@BDAY@)
@DEPTNME@
@RRHLOS@
MRN: @MRN@
SYNOPSIS
@NAME@ is a @AGE@ @SEX@ ***
@NOTESUMMARIES(1&0&0)@
Admitted for
@PROBLEM@
@PROB@
ASSESSMENTS/UPDATES/CONCERNS
NEURO
• Behavioral description:
• Temperature:
• Weakness/Exceptions/Aberrations:
• FC/MAE/ROM?:
• Sedation Vacation today?
CARDS
• Majority rhythm:
• Pertinent Meds
• MAP Goal
• PRNs
• Blood Thinners?
RESP
• CPAP today?
o Patient tolerance/duration:
• Vent Settings:
• Daily ABGs?
• Secretions:
• Home equipment?
GI
• @DIETORDERSNOQUESTIONS@
• H2O Flushes?
• Route:
• BG Checks?:
GU
• Foley y/n?
• Indication:
• Urine appearance:
• 24 Hour I/O @IOBRIEF@
• NOC Shift Net: m L
SKIN
• Intact?
• Wounds:
• New/old?
PAIN
• CPOT 0
• Management:
PROPHYLAXIS
• Heparin subcutaneous
• Protonix
• SCD
LABS
• Lytes repleted:
• Serial collection?:
• Daily CBC/CMP
• Criticals:
• Microbio:
RESTRAINTS
• Y/N:
• Reason:
MAIN PROBLEM TODAY
1.
PT GOALS
1.
PROVIDER PLANS
*see provider notes for more
NOTABLE INTERVENTIONS
- OTHER
• Family matters:
PRECAUTIONS
• Isolation
• Inpatient
CONSULTANTS
- @CONORDS@
REMAINING TASKS ENDORSED TO NEXT RN:
- DRIPS & VENT
ICU DRIPS & CONTINUOUS IV’s
LINES:
PIVs
•
CENTRAL
•
VENT SETTINGS / ABGs
Vent Settings:
@IPVITALS(2:6500)@
@IPVITALS(2:6501)@
@IPVITALS(2:6503)@
@IPVITALS(2:1000173)@
@IPVITALS(2:6506)@
@IPVITALS(2:6516)@
Arterial Blood Gas result:
pH ***;
pO2 ***;
pCO2 ***;
HCO3 ***,
%O2 Sat ***.
VITALS
VITALS
24 Hour Min / Max Current
@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@
@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@
@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@
@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@
@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@
Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@
LABS
@LABBRIEF(NA,CL,BUN,K,CO2,CREATININE,WBC,GLUCOSE)@
@LABBRIEF(WBC,HGB,HCT,PLATELETS)@
@LABBRIEF(PT,INR,APTT)@
@LABBRIEF(CA,MG,PHOS)@
@LABBRIEF(ALB)@
IMAGING
@IMAGERESULTS48H@
ORDERS
MEDS & ACTIVE ORDERS
See MAR
@ACTIVEORD@
@DCMED@
NURSING PLAN
Maintenance Tasks
-add/maintain PIVs, check need for CVC/Foley
-monitor electrolytes
-strict I/o when ordered
-neuro checks periodically
-monitor HGB; check s/s bleeding
-ensure airway trach patency
-elevate arms, if app
-d/w attending pt status
-turned pt q2h
-fall risk observed
-wound care/prevention as necessary
-skin checks q shift w/RN 4 eyes verification
Report given to oncoming RN, , at end of shift, who then assumed all care.
Howie —-, BSN, RN, CCRN
Electronic Signature
@TD@ @NOW@