Common Orders and Note writing in Epic during the NICU
Writing Admission Orders
Go to order tab in Epic and under Order Sets type NICU Admission Orders.
Go through the orders and select appropriate orders for your patient
Writing History and Physical
Start by clicking the admission tab.
Then Click Problem List - H&P
Enter appropriate problems for your patient and enter and Assessment and Plan under "Current Assessment & Plan Note".
Next select Subjective/Objective tab and enter dot phrase .NICUHP3.
Enter physical exam and appropriate information in the body of the H and P template
Next select Subjective/Objective tab and enter dot phrase .NICUHP3.
Enter physical exam and appropriate information in the body of the H and P template
Writing daily progress Note
Click Rounding tab and select Subjective/Objective tab.
Under Subjective & Objective enter dot phrase .nicuprog2 (note: on DOL #2 the H&P subjective and objective will carry over so will need to be deleted and new dot phrase will need to be entered. On each subsequent day the Subjective and Objective will automatically populate but the physical exam and any overnight changes should be updated daily.)
Under Subjective & Objective enter dot phrase .nicuprog2 (note: on DOL #2 the H&P subjective and objective will carry over so will need to be deleted and new dot phrase will need to be entered. On each subsequent day the Subjective and Objective will automatically populate but the physical exam and any overnight changes should be updated daily.)
Next under the Rounding tab select the Problem List.
Update Assessment and Plan for all active problems (note: Not all problems need to be updated everyday, if a problem was not discussed on rounds it is not necessary to update the Assessment and Plan. Be sure to update all active of pertinent plans including the primary Prematurity diagnosis problem.)
Update Assessment and Plan for all active problems (note: Not all problems need to be updated everyday, if a problem was not discussed on rounds it is not necessary to update the Assessment and Plan. Be sure to update all active of pertinent plans including the primary Prematurity diagnosis problem.)
When completed the Subjective/Objective and the Problem list click Generate Note and sign the note and forward to the attending that rounded with you on the patient that day.
Common Order Sets:
NICU Blood transfusion Order set
In order sets tab type NICU Blood Transfusion and Feeding Orders
Click the appropriate order for PRBC, platelet, or FFP transfusion for the patient. Remember to select Leukoreduced and Irradiated products.
Sepsis Order Set
In the order set tab type NICU Sepsis, Suspected
Select appropriate orders for lab work and medications for the patient.
Maintenance IVF Order Set
In Manage Order tab type NICU Maintenance Fluids Panel
Select the desired IVF from the drop box and enter appropriate rate for the patient
Procedure Notes
Under the Procedure Tab click Procedure Notes
Select the procedure that was performed and enter accurate description of the procedure. Then sign the note and forward to the supervising attending.