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ED and Hospital
The recording steps are the same as in clinic. What changes is how you pick the patient, which note types you use, and a few habits that make the draft better. Start with Abridge: Your First Visit, which walks through a clinic visit end to end, then read the section for where you work.
Emergency Department
Pick the patient from the Trackboard, and create the note before the patient is discharged.
An ED visit is several conversations
After the first note is created, choose Record More, record again, then Update Note, and Abridge refreshes the note with the new context.
Do not edit the note in Hyperspace between recordings, or you lose the ability to add more ambient content.
HPI and medical decision making default to concise. Switch to comprehensive when you need more detail; that setting lives on Make It Write Like You.
- Narrate your chart review first, pause the recording, then resume when you are with the patient.
- State your differential and your medical decision making out loud.
Hospital
Pick the patient from your Patient List. Back to back admissions are where this saves the most time.
Three note types
H&P, Progress Note, and Consult. Choose the type before you record. Epic holds one unsigned note of each type at a time, so any note you left incomplete has to be signed or deleted before you can create another of that same type. If you started a progress note a week ago with Ambient, pulled the draft in, and never signed it, you cannot create another Ambient progress note until that old one is signed or deleted.
Pull a prior note forward
When you start a Progress Note you can pull forward a prior note from the past 72 hours. The assessment and plan carries into today's note and updates from the new conversation: existing problems stay in order, and new ones are added.
- Pre-chart by recording the interval history from rounds, or from other staff, before you enter the room.
- Monologue any extra context before or after the visit.
- Complete recordings within 24 hours.
Heard in Visit Recording (HIVR), where orders you say out loud are queued for your signature, is available for outpatient visits only at this time and is coming to the ED and hospital later. Until then, in the ED and the hospital, place orders as you normally do. Visit Diagnoses can still be pulled into the diagnosis section from the Abridge tab.
More on Abridge
Verify the diagnoses Abridge heard and sign your orders. Clinic visits only.
Verify and sign →Ten minutes of settings, and every future note reads the way you write.
Set your preferences →