What is a sensitive note in epic?

What is a sensitive note in Epic?

Summary:

In Epic, a sensitive note refers to a type of documentation that contains confidential or sensitive information about a patient’s medical condition or personal circumstances. These notes are kept private and are only accessible to authorized medical professionals who are involved in the patient’s care.

Key Points:

1. A sensitive note in Epic contains confidential or sensitive information.
2. These notes are only accessible to authorized medical professionals.
3. Sensitive notes are used to record information that may impact a patient’s treatment or care.
4. Examples of sensitive information include mental health history, substance abuse issues, or HIV status.
5. Epic has strict security measures in place to protect the confidentiality of sensitive notes.
6. Sensitive notes can only be viewed by medical professionals involved in the patient’s care.
7. Patients do not have direct access to sensitive notes in their MyChart account.
8. Medical professionals must ensure proper documentation and privacy when creating sensitive notes.
9. Violations of privacy or unauthorized access to sensitive notes can result in disciplinary actions.
10. Providers must follow legal and ethical guidelines when handling sensitive information.

Questions and Answers:

1. How do you write a consult note in Epic?
Answer: To write a consult note in Epic, go to the Notes Activity tab and compose a note. At the bottom of the note, add CC: and the name of the desired recipient(s). Recipient options include individual physicians, a facility, or a physician group.

2. What is the difference between MyChart and Epic?
Answer: MyChart is Epic’s patient portal. It is a secure means for patients to access parts of their health records through a web browser and cell-phone apps. Epic, on the other hand, is the electronic health record (EHR) system used by healthcare providers to document patient information and manage their care.

3. How do I find old patients in Epic?
Answer: To find old patients in Epic, you can use the Appointments icon on the toolbar and press Ctrl + 1. Alternatively, you can use the Epic Button selections. Type the patient information into the Name/ID field, such as the Medical Record Number or the first 3 letters of the last name followed by a comma and the first 3 letters of the patient’s first name. Click the “Find Patient” button to search for old patients.

4. What is considered a consult note in Epic?
Answer: A consult note in Epic is generated as part of a request from a clinician for an opinion or advice from another clinician. It serves to document the communication and collaboration between healthcare professionals regarding a patient’s care. Consult notes provide valuable information and recommendations to guide treatment decisions.

5. What are consult notes in Epic?
Answer: Consult notes in Epic refer to the documentation created in response to a request from a clinician for an opinion or advice from another clinician. These notes contain relevant information, assessment findings, recommendations, and any actions taken regarding the patient’s care or treatment plan.

6. Can patients see notes in Epic?
Answer: Patients can see certain types of notes in Epic through their MyChart account. However, result notes, which may contain sensitive information or test results requiring interpretation by a healthcare provider, are typically not viewable by patients.

7. Is Epic an EMR or EHR?
Answer: Epic is a well-known electronic health record (EHR) system provider that has been used by hospitals, independent practices, skilled nurses, and businesses of all sizes. It offers a comprehensive platform for storing, managing, and accessing patient medical records, while also facilitating communication and coordination among healthcare providers.

8. What does CSN mean in Epic?
Answer: CSN stands for Contact Serial Number in Epic. This unique identifier is assigned to each patient visit, such as an appointment or admission. It helps in tracking and referencing specific encounters within a patient’s overall medical history.

9. What are the three types of consultation?
Answer: The three types of consultation models are:

• Collaborative-dependent: This model involves close collaboration and interaction between the consulting clinician and the requesting clinician.
• Collaborative-interdependent: In this model, the consulting clinician and the requesting clinician work together as equals, sharing knowledge and making joint decisions.
• Triadic-dependent: This model involves a three-way relationship between the consulting clinician, the requesting clinician, and the patient. It emphasizes active participation and shared decision-making.

10. What are the 5 C’s of consult?
Answer: The 5 C’s of consult refer to a model designed to standardize and formalize the process of communication in consultations. They are:

• Contact: Establishing communication and initiating the consult.
• Communicate: Sharing information, concerns, and relevant details between clinicians.
• Core Question: Identifying the main question or issue to be addressed during the consult.
• Collaborate: Engaging in joint decision-making and developing a collaborative plan.
• Close the Loop: Reviewing and repeating key information to ensure understanding and follow-through.

11. What are the 4 main forms of the consultation process?
Answer: The four main forms of the consultation process are as follows:

Stage 1	Formulation of ideas or proposals
Stage 2	Consultation on a proposal or implementation of government direction/s
Stage 3	Considering responses and providing feedback
Stage 4	Making a final decision and implementing it

12. What are the 3 Rs of consultation?
Answer: The three “R’s” of consultation codes are:

• Request: The initial request for a consultation from a clinician to another clinician.
• Render: The process of providing the consult and generating the necessary documentation.
• Reply: The response or feedback given to the requesting clinician regarding the consult findings and recommendations.

13. Can patients see their own medical records in Epic?
Answer: Yes, patients can access parts of their medical records through MyChart, Epic’s patient portal. They can view test results, medications, allergies, immunizations, and appointment schedules. However, access to certain sensitive notes or result notes may be restricted to ensure patient safety and confidentiality.

14. How do medical professionals ensure privacy when creating sensitive notes in Epic?
Answer: Medical professionals must adhere to strict privacy and documentation guidelines when creating sensitive notes in Epic. They should ensure that only authorized individuals have access to these notes and that they are properly labeled as sensitive. It is important to handle sensitive information with care and follow the legal and ethical requirements of patient privacy and confidentiality.

15. What are examples of sensitive information in Epic?
Answer: In Epic, examples of sensitive information that may be documented in notes include mental health history, substance abuse issues, sexual health, domestic violence, HIV status, genetic test results, or any other condition or circumstance that could potentially cause harm, discrimination, or distress if disclosed without proper consent.