Scribing Notes and Routing to Providers User Guide November 11, 2016

Transcription

1 Scribing Ntes and Ruting t Prviders User Guide Nvember 11, 2016 Belw is a guide cvering the steps t be cmpleted in the Epic System fr a nn-credentialed users t transcribe / scribe an ambulatry visit nte and rute the pended ntes fr the prvider s signature, s that the nte will becme a part f the final medical recrd. Please nte: prvider scribes / transcriptinists will nt have the ability t practice this guide in the Playgrund Envirnment (PLY) - please retain this User Guide t supprt yur actual wrk in the Prductin envirnment. Try It Out 1. Lgin t Epic Hyperspace PROD (prductin envirnment) using yur persnal username and passwrd. 2. Imprtant: Users with multiple rles will need t review the JOB selectin screen that appears immediately after lgin. Using the selectin buttn [ ] review the available Jb functins and select yur Scribe / Transcriptinist Rle if yu are assigned multiple rles. Select yur rle and Click OK. 3. Select yur Department and cmplete yur lgin by clicking OK. Page 1 f 5

2 4. Yur next step will be t select a specific patient encunter. In an ambulatry department yu ll have tw majr ways t lcate yur patient. FROM A SCHEDULE If yur prfile is cnfigured t display a prvider r department schedule, yu ll be able t review the day s schedule frm the upper ½ f the screen duble click n the apprpriate Patient/Appintment t pen the chart t begin dcumenting. SEARCHING FOR AN ENCOUNTER If yu dn t have a precnfigured schedule yu ll be able t search fr a patient and select the apprpriate encunter t assciate with yur nte. Frm the main Epic menu (upper left) select ENCOUNTER frm the drp dwn. Alternately, user the Search Bx in the upper right and type ENCOUNTER and left click n Encunter t jump t the encunter search bx. r The encunter search bx will appear. Enter yur search criteria and click the Find Patient buttn t search fr the patient: Page 2 f 5

3 A list f patients matching yur search will appear. Review this list and duble click t select the apprpriate patient: The next bx will cntain a list f encunter recrds fr yur selected patient: Frm this bx duble click the apprpriate encunter t assciate yur nte t. 5. Nw that yu have pened the chart fr the apprpriate patient and encunter, prceed t the Ntes activity t begin yur nte. 6. Cmplete yur nte using either a blank nte (select: r using NteWriter by selecting an available template frm the drp dwn arrw next t the Create Nte in NteWriter Buttn Nte: The department yu are lgged int will determine what NteWriter templates yu will have access t. Please review with yur department what templates yu will use. Page 3 f 5

4 7. As a scribe/transcriptinist yu ll ntice that yur nte will have Pend n saving nte in the lwer left. This indicates yur nte will nt be immediately added t the medical recrd f the patient, but will be pending the apprval f the prvider. 8. Enter the cntents f yur nte and chse the Accept buttn at the bttm right f the screen. 9. T rute this nte t the prvider t sign, yu ll use the Wrap-Up activity (left side navigatin). 10. Within the wrap up activity, yu ll see the fllw up sectin. Yu may need t scll dwn as it s ne f the last activities in the sectin. Within the fllw up sectin, yu ll mst ften need t expand [ ] the lwer half f the sectin, such that the Send Chart Upn Clsing Wrkspace Sectin is visible. 11. In the Recipient bx f the Send Chart Upn Clsing Wrkspace add the name f the prvider yu are scribing fr. [tip: yu can search by their lgin ID, rather than having t use name.] Page 4 f 5

5 12. At this pint just clse the wrkspace (use the X t the right f the patient s name n the tab at the tp f the screen.) The prvider will see a nte in their InBasket in the flder CC d Charts: They must duble click n the chart, review the nte and sign it, then clse the encunter nrmally. Page 5 f 5