How to Search for a Patient in Epic

Chart checking is the process of reviewing a patient's full record before rounding, and it begins with learning how to search for a patient in Epic and open their chart. This guide walks you through locating a patient on your list and then systematically reviewing their vitals, labs, imaging, notes, intake and output, medications, and orders. Complete this process each morning for any patient who has been under your care for several days or who was admitted overnight.

Prerequisites

• Access to Epic with permissions to view patient charts.
• The patient must appear on your assigned list (for example, GenSearch or Gen Surg).
• The patient should be one admitted to you for several days or overnight, since chart checking is intended for ongoing inpatient care.

1

Search for the patient and open their chart

Go to your GenSearch or Gen Surg patient list in Epic to search for the patient you need to review. Identify the correct patient from the list, which displays room/bed, name, age/gender, problem, and attending. Select the patient, then click Open Chart to access their full record.

5

Review imaging

Go to the Imaging tab within Chart Review and click Service Dates to sort results so the most recent images appear at the top. Review the radiology reports and click into the actual images if needed. Check for any EKGs under the appropriate tab as well.

7

Read notes thoroughly

Read through the available notes carefully, especially if this is your first time seeing the patient. A discharge summary, for example, can show medications, review of systems, the most recent vital signs, and physical exam findings in one place.

8

Review intake and output

Return to the Summary tab and click Intake/Output to review all recorded I&O data, including urine output, IV fluid intake, oral intake, and any other relevant fluids or medications. Check for additional sources of intake or output, such as an NG tube, and make sure these are accounted for in your review.

10

Manage orders

Go to the Manage Orders tab and review all active, held, and discontinued orders for the patient. Remove any extra or outdated orders to keep the chart organized and current, and confirm that all remaining orders are appropriate for the patient's ongoing care.

Key points to remember

• Always compare current data to previous days to spot trends.
• Pay close attention to supplemental oxygen, new lab abnormalities, and new imaging findings.
• Nursing notes and discharge summaries often contain critical information not found elsewhere in the chart.
• Be especially thorough when reviewing a patient for the first time.

Summary

By searching for your patient in Epic and working through the Summary, Labs, Imaging, Notes, Intake/Output, Medication History, and Manage Orders sections, you complete a comprehensive and efficient chart review. Following these steps each morning helps ensure that all critical aspects of your patient's care are reviewed and documented.