Basic Electronic Medical Record (EMR) Techniques: Summarizing Patient Data

OVERVIEW

There are sections of the EMR that can be optimized to summarize various types of patient data in more intuitive forms. This can include anything from the patient’s vitals to their insulin requirements and more.

While the EMR can be a powerful tool often times the format of the patient’s information can be confusing to interpret. Organizing and optimizing the format of sections that summarize clinical information about the patient is key (image source).

This page includes tutorial videos in each of its sections (that demonstrates how to conduct these techniques on the UCSF EPIC EMR system). All of these videos can be found in this folder here.

*While the preview feature for these videos may not work on certain mobile browsers, the videos can still be viewed if they are given time to load/the page is refreshed. 

HOW TO USE THE SUMMARY SECTION AND PERSONALIZE IT (ADD TABS)

The first step will be becoming familiar with where the summary section is in the chart and how to personalize it (add tabs/subsections).

Watch a video here on how to use the summary section and personalize it by adding tabs/sections (demonstrated on the UCSF EPIC EMR)

HIGHLIGHTING SPECIFIC SECTIONS TO ADD TO THE PATIENT SUMMARY

This portion of the guide is very specific to the EPIC EMR that is found in the UCSF system however the concepts can be applied to other settings. Once you are familiar with how to add sections to the patient summary (shown in the above video) the following are very important sections that can be added to your EPIC account that will serve you well. Videos have been included that go into more depth about the value of each section. The names of each section are included (these relate to those used at the UCSF parnassus EPIC system however can sometimes be used at other institutions as well. Use the names below to add these tabs to your patient summary section. 

  1. Summary Of Vital Signs (Video): called “Vitals” this section lists out the vital signs very clearly by time collected.
  2. General Patient Data (Video): there are actually three options to use here “Comp“, “Comp By Organ“, and “RX Accordion“. These tabs organize a wide range of patient data into slightly different formats that are very useful.
  3. Insulin Summary (Video): called “Insulin/GI/Nutrition” this section shows the blood sugar trend and insulin usage of patients.
  4. Pain Summary (Video): called “Pain” this section shows the amount of pain medications used by the patient (and corresponding vitals).
  5. Transfusion Summary (Video): called “Blood Transfusion History” this tab shows the amount and date of the blood products received by patients.
  6. Medication Administration Report/MAR Report (Video): called “MAR Report” this section shows every medication that was given to the patient, its dose, and its time.
  7. Fever/Antibiotic Summary (Video): called “Fever/Antibiotics” this section shows the fever curve, and WBC count all relative to the doses and times of all the antibiotics and antimicrobials that have ever been given to the patient.
  8. Microbiology Summary (Video): called “Microbiology- By Date Collected” this section summarizes all of the microbiology data collected on the patient by the date that it was collected.
  9. Lines/Drains/Devices – LDA Summary (Video): called “LDA” this section organizes all of the lines, drains, and devices that a patient has (and their placement date/removal date.
  10. Facesheet (Video): called “Facesheet” this includes important patient demographics (such as contact information for both the patient as well as caregivers).
  11. Discharge Info Summary (Video): called “Discharge” this section organizes relevant information that relates to a patients upcoming discharge (such as case manager notes, physical therapy recommendations, etc).

 

 

Page Updated: 06.22.2019