Learn to use available tools in EPIC
In your assessment, remember diagnoses are nouns
E/F, R/O ie evaluate for, or rule outs are verbs and thus go into the plans
In your plans
Data that is important but missing, eg structured cognitive assessments, should be included in the plan as a missing element to be collected
While writing orders for medications help the reader by using clear consistent language
Medications are any ONE of the following:
Continued – ie at same dose and schedule
Increased or tapered up
Decreased or tapered down
Stopped, discontinued or terminated (helpful to add a few words on reason)
Start, initiated, (helpful to add a few words on target sx)
Crossover ( followed by taper up “x” and taper down “y” comments)