Epic EMR Etiquette
Shared chart standards for Freeman Medical Staff. Adapted with permission from the Emplify Health EHR Etiquette Guide. Reviewed and maintained by the Provider Advisory Council.
Draft. Items marked Pending review are awaiting final confirmation.
Why this exists
The record in Epic is shared by every clinician, care team, and patient across every Freeman setting. Chart maintenance is a shared responsibility, not a single person's job. These principles guide the Medical Staff; they do not replace clinical judgment.
General principles
- The chart belongs to the patient and should reflect their current state of health.
- Every clinician contributes to chart maintenance for the patients they care for. Primary responsibility rests with the primary care clinician and any co-managing specialists.
- Documentation is completed in a timely manner. Care depends on a complete record.
- You are responsible for the accuracy of your entries, even when the task is delegated.
- Respect other clinicians' entries, but accuracy and specificity of diagnosis come first.
Problem List
The Problem List gives the whole care team a clear picture of the patient's current health. It is shared by primary care and every specialty.
Standards
- Patient-centered.
- No duplicate, inaccurate, inappropriate, or lapsed problems.
- Problems carry appropriate specificity (HCC).
- Every relevant current problem is present.
A problem is added when the plan is made and resolved when the plan is complete or the problem is no longer relevant. Longitudinal states (for example, post-transplant) stay on the list.
Who maintains it
Physicians and APPs own the Problem List. It is within their scope to diagnose, and they are responsible for its upkeep. Other care team members support it within limits:
| ACTION | PHYSICIANS AND APPS | OTHER CARE TEAM MEMBERS |
|---|---|---|
| Add a problem already documented elsewhere in the chart (for example, a visit diagnosis) | Yes | Yes, as data entry only |
| Add a unifying problem in their own domain (for example, a therapist adds the single diagnosis being treated) | Yes | Yes |
| Add problems not otherwise documented | Yes | No |
| Resolve or delete problems | Yes | Yes, during reconciliation with the patient |
| Add a problem when directed by a physician or APP | Yes | Yes |
| Add a non-medical factor affecting health (social, financial) | Yes | Yes |
Care team members do not add problems based on lab results without direction from a clinician.
Belongs on the Problem List
| CATEGORY | EXAMPLES |
|---|---|
| Chronic problems needing treatment, screening, or monitoring | Type 2 diabetes, hypertension, renal insufficiency |
| Recurring acute problems | Recurrent UTIs, recurrent shoulder dislocation |
| Problems requiring chronic scheduled or PRN medication | Anxiety, migraine, SBE prophylaxis candidate |
| Problems requiring lab monitoring | Thyroid disease, long-term anticoagulant use |
| Acute symptom under active evaluation | Abdominal pain, changing skin lesion |
| Active or relapsing chemical dependency | Tobacco use, opioid dependence |
| Family history conveying significant risk | BRCA positive, Huntington's disease |
| Chronic mental health conditions | Depression, bipolar disorder |
| Positive screening tests affecting ongoing care | Abnormal Pap, PSA, or PPD |
Does not belong
| CATEGORY | EXAMPLES |
|---|---|
| Inactive or historical problems and completed surgeries | Meningitis, appendectomy |
| Minor self-limited illnesses | URI, rash |
| Non-problems | Physical exam, vaccination, counseling |
| Family history of no significant risk | Family history of appendectomy |
| Screening study diagnoses | Screening mammogram |
| Symptoms when a diagnosis exists | Cough when asthma is already listed |
| General diagnosis when a specific one exists | "Hearing loss" instead of sensorineural hearing loss of left ear |
Maintenance
- Review at every visit. Add when problems arise, resolve when no longer relevant.
- Update when consult letters or results arrive that change care.
- Add, edit, resolve, or delete regardless of who entered the problem or from which specialty, including improving specificity.
- When resolving, move to Past Medical History when appropriate.
- Remove duplicates and resolved acute problems (for example, a healed fracture).
Overview section (per problem)
Short annotations that help every reader understand the problem. Replace dated information rather than stacking it. Not for personal reminders.
Examples: "Patient declines mental health referral." "Contemplative phase of smoking cessation." "Stress thallium normal on Pending review: date." "Echo on Pending review: date normal."
Care Coordination Note (top of Problem List)
Information useful across specialties and to outside providers through Care Everywhere. Do not erase others' entries unless no longer relevant.
Examples: temporary change in care plan (drug substitution for shortage), temporary change in living situation, community partners involved, services the patient receives, adolescent sensitive encounters that cannot be shared beyond the patient.
Inpatient
- Identify the Principal Problem. It may change during the stay; the final diagnosis is marked Principal.
- Mark every problem addressed during the stay as a Hospital Problem.
- At discharge, reconcile the list so it is accurate for ongoing care.
Past Medical History
Document problems with historical importance or implications for future health. Leave out self-limited problems, symptoms, remote problems without continued importance, events, family history, and social history. Significant active problems on the Problem List should also appear in PMH. Clinicians or nursing staff may update.
Past Surgical History
All surgeries and significant procedures. A procedure may also sit on the Problem List during recovery or when it has long-term implications (s/p splenectomy, s/p ileostomy). A member of the surgical team updates PSH once the procedure is complete. Clinicians or nursing staff may update.
Medication List
Review and update at every encounter through medication reconciliation. Set end dates for short-term medications, mark chronic medications long-term with the push pin, delete duplicates, and add the diagnosis indication inside the order. The indication prints on the After Visit Summary and in the Sig so patients know why they take each medication.
Allergies
Current and accurate at all times. Only drug and food allergies, reactions, and intolerances belong here.
- Enter the specific drug and its reaction. When several drugs in one class are involved, enter the class (for example, Penicillin rather than amoxicillin, Augmentin, and dicloxacillin separately).
- Document the reaction as symptoms; severity autofills.
- Choose the reaction type: Allergy (immune response), Intolerance (side effect), Contraindication (interaction or disease-based), or Unspecified.
- Environmental allergies go on the Problem List, not the Allergies list. Allergies to treatment extracts stay in Allergies.
Mark as Reviewed
After reviewing and updating a section, click Mark as Reviewed. Epic records the date and time in the encounter report. The Review activity contains Allergies, Medications, Problem List, Tobacco, Medical, Surgical, and Family History together, so one click covers all of them. Do this every visit.
Notes
Be concise. Note bloat buries the information that matters. Data already in the chart (histories, medication list, allergies, results) does not need to be repeated in the note. "CBC, CMP, and TSH reviewed and normal" is enough. The encounter's Detailed Report, which is what goes to outside organizations, already carries the rest.
Your patient reads your note. Write accurately and with that reader in mind.
Collapsible Subjective and Objective SmartLinks in SOAP or APSO notes let readers get to the Assessment and Plan quickly.
No disclaimers. Do not add statements such as "This note was created using voice recognition" or Cures Act notices about peer-to-peer language. They add bloat, provide no protection against errors in the note, and Freeman policy directs their removal.
Ambient documentation consent. Consent for ambient AI documentation (Abridge) is part of Freeman's consent to treat, which is captured electronically and goes live with Epic. No separate consent statement or SmartPhrase is added to the note. If a patient declines ambient recording during a visit, do not record and document the visit conventionally. Pending review: Confirm whether a per-visit decline is documented in the note or elsewhere.
Abbreviations are not always understood, including by patients. Avoid them.
Font. Use the default. Consistency reads as professional.
Templates and macros are efficiency tools, and you are responsible for everything they generate. A comprehensive template on a brief visit can falsely indicate a full review of systems or exam. Proofread every note.
Copy Previous refreshes refreshable SmartLinks but nothing else. Proofread and edit so the note reflects today's encounter.
Copy and paste (Windows clipboard) is discouraged. It does not refresh SmartLinks, so yesterday's vitals can land in today's note.
SmartLinks are only as accurate as their source. Keep the Problem List and Medication List current or the note inherits the error.
Consults
Requesting a consult is a critical point in patient care and requires direct communication. Place the consult order and communicate the reason directly to the consultant by phone, page, or Secure Chat. Timing is the requester's judgment based on urgency, but it happens before the consultant is expected to see the patient. The consultant responds within bylaws timeframes and communicates back after evaluating the patient.
Placing a consult order alone is not communication.
Communication is by physicians and APPs. Students may communicate at their supervisor's discretion. Another provider on the same service may communicate if they can give the consultant the same clarity as the ordering provider.
Hospital Course
The hospital course note is a running summary of the stay and feeds the discharge summary. Only the primary team that will discharge the patient modifies it. Other providers edit only with the primary team's permission.
Discharge Orders and Handoff
Freeman's standing norm is that inpatient-only providers do not place outpatient orders. Follow-up testing after discharge is arranged by the primary care or receiving clinician, not ordered from the inpatient encounter. Pending review: Standing norm pending a formal policy.
- The discharging clinician documents the follow-up plan clearly in the discharge summary, including any testing the primary care clinician should arrange and when.
- The discharging clinician determines whether direct communication with the primary care clinician (phone, Secure Chat, In Basket) is needed beyond the discharge summary.
- Patients following up outside Freeman: the discharging clinician communicates with the outside clinician; the patient carries more responsibility for timely follow-up.
- Patients without a primary care clinician: document the plan to establish care.
Health Maintenance
Health Maintenance prompts the care team on preventive care. Address and update care gaps at each encounter. Use the Healthy Planet sidebar report under the This Visit tab for care gaps; the Care Gap SmartSet places orders that are due soon or overdue. Adjust schedules with Edit Modifiers and patient-specific goals through the Goals button in the Rooming tab.
After Visit Summary
The AVS tells the patient what happened and what to do next. It should be:
- Understandable regardless of health literacy.
- In patient-friendly language and, when possible, the patient's preferred written language. Not every section translates; review with a medical interpreter when English is not preferred.
- Direct, most important information first, need-to-know over nice-to-know.
- Specific about next actions, broken into small steps.
- Organized with bullets, lists, and icons.
- Printed in inpatient and ED settings; printed on request in clinics.
In Basket
Your In Basket is part of the patient record and part of your daily work. Review it every working day, act on results and messages in a timely manner, and route messages to the correct recipient or pool rather than an individual who may be away. Set coverage before time off so nothing waits. Pending review: Freeman In Basket policy, including response-time expectations, pending.
Open Notes and Information Blocking
Under the 21st Century Cures Act, patient information is available to patients automatically through MyFreemanHealth (MyChart) as soon as it is final. All notes default to shared. Unshare only for one of four reasons:
- Sharing is reasonably likely to endanger the life or physical safety of the patient or another person.
- The patient or legal representative asked that it not be shared.
- Legal concerns.
- The patient consented at study enrollment to have notes withheld that would compromise a clinical trial.
Nearly all results release to the patient immediately. Lab and radiology results, including the narrative, go to MyFreemanHealth the moment they are final, with no delay for provider review. Preliminary results wait for Final. Expect patients to see results before you do and set that expectation during the visit, especially before ordering tests with sensitive results. Pending review: Any delayed-release categories in the Freeman build will be listed here.
Proxy users see results on release and notes when the encounter is signed. Adolescent proxies do not. Patients can revoke proxy access at any time and the proxy is not notified.
Secure Chat
Secure Chat replaces Mobile Heartbeat at go-live. It runs in Hyperspace, Haiku (phone), and Canto (tablet), with push notifications. Secure Chat is integrated with Freeman's phone platform Pending review: Epic VoIP integration; confirm platform name. Providers who need to receive both internal and external calls will have a DID number (direct dial from outside) and a DN number (internal extension). Most other staff will have a DN number.
What it does
- Shows when a message has been Seen.
- Attaches the patient so the recipient knows who you mean and can open the chart in one tap.
- Supports availability status, groups, and forwarding.
- Three priority levels: Normal (no time expectation), Important (response within 20 minutes), Urgent (response within 5 minutes, breaks through a silenced phone, restricted to selected roles).
Availability
| STATUS | EXPECTATION | NOTIFICATIONS |
|---|---|---|
| Available | Sees and responds within 1 to 2 hours | Push notification |
| Busy | Sees and responds within 4 hours | Push notification |
| Do Not Disturb | Sees and responds next day or next business day | No push; only Urgent breaks through |
| Offline | Will not see messages until back online | Cannot send, receive, or be added to threads |
Send only to people marked Available or Busy. Surgeons and proceduralists set up forwarding once (to a person or a role such as circulating nurse); the system marks them Busy during procedures.
Best practices
- Secure Chat is for brief, non-emergent communication. Emergent communication is by phone or face to face.
- Messages are not documentation, but they can be copied into the chart. Use professional language.
- SMS, iMessage, and other messaging apps are prohibited for any patient-related communication.
- Attach the patient to every patient-related message.
- Say where you are sending from if it is not obvious.
- Every message has a clear ask.
- One summarized message beats several short ones. The recipient is alerted every time.
- Do not send "thanks" or "ok." The sender can see you read it; the understanding is that you will act unless you have a question.
- Non-emergent orders can be shared with a clinician in Secure Chat. The clinician signs, modifies, or deletes them. CPOE remains the standard.
- Do not leave a conversation; it alerts everyone in it. Let messages fall off on their own.
Secure Chat messages remain visible for Pending review: 30 days and then fall off automatically.
Paging. Pending review: Secure Chat paging, including which departments use it and how CODE paging is handled, will be documented here once the Freeman build is confirmed.