Physical Therapy EPIC Charting (for PT Students) Basic EPIC Print your list off for the day. Chart review for each patient.
Charting/Documenting in EPIC Write your PT note (Evaluation, Treatment or Contact Note). Use .ippte2 (eval) and .ipptt2 (treat) dot phrases for notes. Do your PT Visit Planning. Use proper format for frequency: 5x/week Mon 1/5. In the priority column only state information that is important for the next therapist to know prior to reading the note! (Ie: 2 person, Spanish speaking, 10:00 caregiver education). Make (or status for treatments) your goals in the Care Plan section. Do your Patient Education status in Patient Education. Keep track of patient charges (for CI to enter) Consult Sign Off if no additional PT needs “Extra” communication includes any patient that could use phase 2 cardiac rehab or that are new amputee/limb salvage patient’s – send in-basket message to Connie Amos Additionally send an in-basket message to “Rehab Inpatient Followup” for pt’s in need of out-pt PT services – type in “p reh m”. Drag patients into the shared folder “Rehab Navigator” if new SCI, TBI or CVA Patient Handouts (4 ways to obtain) Go to Google Chrome Icon on computer: Login
[email protected] Password: Willamette In EPIC, through Patient Instructions (use .rehab and find the proper handout) Old fashioned paper handouts from department or from RN units For students – you will need to have your CI log in to physiotools. Physiotools: Go to: ohsuphysiotools.com. Login name: your CI’s OHSU ID, password: OHSU001
Friday Extras Put priority patients in the Weekend List. This includes ortho patients, pt’s to DC to IPR the following Mon/Tue and patient’s with potential DC home over weekend. Additionally pts with NO funding and need therapy to DC home can go on this list. This list will also include new evals.
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Detailed Breakdown of EPIC charting 1. Entering PT Note: In “Notes” tab on left, click on “New Note” in top left corner. Enter in “Plan of Care” as the type of note. Use the dot phrase “.ipptte2” for an eval, use “.ipptt2” for a treatment. Use the F2 button to go through the note and fill out information. If doing a treatment note, you can copy and paste the “Brief Hospital Course” and “Precautions” section from the last PT note (or OT note), but please check to make sure this information is complete and accurate! Update with NEW information throughout the pt’s stay!! The “Status Update” section should have any new information since the last PT note (ie: “pt with low O2 sats yesterday, now resolved and on 2 L O2 per RN”, or “pt transferred up from ICU to ward on 5/25/10”). Please avoid saying “POD 2” or “went to OR yesterday”, use dates instead as this helps out for the next person not having to change information. Also, make sure if the note before yours had an important “Status Update” to now include/add this information in your “Brief Hospital Course”. When finished with your note press the “Accept” button or you can push “Pend” to come back to the note later. 2. Status/Make Goals in Care Plan Section: - Push on the “Care Plan” tab on the LEFT side. - If making new goals (eval), press on “Apply Template” on the top. Type in “Rehab” and make the selection (ie: Functional Mobility) for what type of goals you want to set. It is OK to put all your goals in one section. After you’ve selected goals, click on the goal, then select “Edit” to make a goal. Write your goals and select an “Expected end date” (usually 1-2 weeks), then press accept. - If you are doing a tx status, just press on the “Document” tab and then select the most appropriate option from the “Outcome” drop down list. Then press accept. Make sure the goals are still accurate for a patient and update appropriately (ie: if no gait goal written at eval, but pt is now appropriate for gait, please add this goal on using the “edit” button.) 3. Patient Education Click on “Patient Education” tab on LEFT side of screen. Go to “Unresolved Education” on the top. Under “General Teaching Goals” there is a generic “Rehabilitation” section on every chart. You can use this section or make your own patient specific goal. Select the appropriate options for the education you provided (you can just click on the blue words that are appropriate for the patient) and then select “File”. 4. PT Visit Planning Click on the “Adult PT Navigator” button on the LEFT side of screen. Click on “Visit Planning”. Enter in all the information: Time in, Time out, Date last seen is TODAY (you can just type in “t”), Planned Frequency should be in the format “5x/week Mon 1/5” and resets on the day the POC starts each week, Future Visit Priority should only include IMPORTANT information that you want to relay to the next therapist that would be helpful when they see their list in the morning (or info for the TL to know, ie: “keep with Holly” or “PT reeval”). Examples include: “2 person”, “Spanish speaking only”, “planned DC 5/28 in AM, needs stair training”. If you do not want to add a X:\OHSU Shared\Restricted\PS\Rehab\ORIENTATION MANUAL\Orientation Manual-Clinical\PT Orientation Files Updated 12/11 HP
comment to this section please put a “-“ as the last filed value will automatically show up. When finished, click on the “Close” tab to file this info.
5. Enter Charges Students have CI enter charges 6. Consult Sign off – for pts you are discharging from PT services In the Adult PT Navigator, Choose “Consult Sign-off”, then COMPLETE the PT order. This will take the person off the PT list.
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