Documentation

Orientation to Electronic Medical Record (EMR) Charting

Swedish uses the "Epic" clinical information system for all chart functions including order entry.

Online training will be provided through HealthStream. Your instructor will provide you instructions for accessing the HealthStream (HLC) website.

Chart Access

Only access charts of the patients you are assigned to provide care for. Not all available patient data is appropriate to access in Epic. Know what is acceptable and unacceptable: click on the link to read Chart Access Guidelines. Inappropriate access can lead to progressive correction action including removal from clinical at Swedish facilities.

Dangerous Abbreviations

Click on the link to review Dangerous Abbreviations.

The use of certain abbreviations have been the cause of significant health care errors. Swedish Medical Center does not allow them to be used anywhere in the patient's medical record.

Procedures and Protocols

Procedures and protocols are the basis for practice and documentation. They are specifically referred to in the patient's plan of care.

Example: A patient receiving anticoagulants should have the aspects of the "Anticoagulant Therapy Protocol" reflected in the Epic Plan of Care.

Unless a plan is documented to the contrary, care must be provided according to the protocol and healthcare practitioners are held legally accountable to that standard. You are able to access these standards when on the patient care units via the Swedish intranet in the "Standards" tab at the top of the page.

Quality Variance Reporting

A Quality Variance is any unexpected occurrence not consistent with the routine operation for the Medical Center or the routine care of a patient. Notify the caregiver you are assigned with or administrative supervisor, and your instructor immediately. Reporting is done with an eQVR using the Datix Reporting Center.