Scribe Color Codes and Patient Care Notes

Color Codes in Scribing

  • Red:

    • Represents "pre-physician"
    • Meaning: Patient is in the room and ready to be seen.

  • Peach:

    • Represents "physician assigned"
    • Action: Open chart, review vitals and triage note, place first provider contact time when walking to the room.

  • Green:

    • Stands for "re-evaluation" or "results returned"
    • Action: Notify the physician that results are back.

  • Baby Blue and Blue:

    • Indicate "pending discharge" and "ready for discharge," respectively.

  • Pink:

    • Signifies admission of the patient.

  • Purple:

    • Stands for "pre-admit" indicating no bed order has been placed and no communication with a hospitalist.

  • Admission (Pink) vs. Pre-Admission (Purple):

    • Admission (Pink) indicates that a bed order is placed and the hospitalist has been notified.

Patient Location and Assignment

  • Identifying Patient Location:

    • Bed number helps determine if a patient is in an actual room or in the ED lobby.
    • Bed numbers 50s indicate waiting room, while 70s indicate radiology waiting.

  • Assigning Yourself to a Patient:

    • Method: Right-click on the patient's name and select "assign me."

Information Review Before Patient Interaction

  • Vital Information to Review:

    • Chief complaints, means of arrival, vitals.

  • Initial Step Before Opening a Note:

    • Enter the first provider contact time using the shortcut (T + tab T + tab).

  • Understanding Patient's Reason for ER Visit:

    • Look at RN note under chief complaint but do not rely solely on this to construct the History of Present Illness (HPI).

Managing Treatment Teams

  • Adding Physicians to Treatment Team:

    • Right-click on patient name, then select "treatment team" and add a team member.
    • Alternatively, while in the patient's chart, click on the attending name in the sidebar and add team members.

  • Distinguishing Attending vs. Team Member:

    • Attending: ED physician or admitting doctor.
    • Team Member: Specialist or consultant.

Levels of Acuity

  • Acuity Levels:
    • Level 1: Resuscitation
    • Level 2: Emergent
    • Level 3: Urgent
    • Level 4: Less urgent
    • Level 5: Non-urgent

Lab and Radiology Results

  • Interpreting Lab Results Notation:

    • Lab [5/3/2]: 5 ordered, 3 will result today, 2 complete.
    • Rad [1/2]: 2 total ordered, 1 complete.
    • Lab {6/6/7}: 7 total ordered, 6 will result today, 6 complete.

  • Tracking EKG Orders:

    • Once ordered, it will appear in EPIC. Check Results Review trackboard to see if ordered or resulted.
    • Use a broken heart symbol for ordered EKGs and a complete heart symbol for completed EKG documentation.

  • Locating EKG in EPIC:

    • Results Review: find EKG, click "View Image".
    • Side-by-side view: find EKG final result, click "View Image".
    • Chart Review under the CARD tab: find EKG, click "View Image".

Documentation Requirements

  • Documenting Rechecks:

    • To be completed in the ED course.

  • Home Screen Equivalent:

    • ED Navigator takes you back to the ED note in a patient’s chart.

  • Admitted Patient Disposition Tab:

    • Ensure two sections are completed: Disposition and Impressions.

  • Discharged Patient Disposition Tab:

    • Must complete four sections: Disposition, Impressions, Follow up, Instructions (also includes pharmacy and work note).

  • Standard Follow-ups Post-Discharge:

    • Always provide follow-ups for this department, the primary care physician (PCP), and specialist referral as needed.

Reviewing Medical Records

  • Tab for Medical Records:

    • Use CareEverywhere, Chart Review, and Results Review.

  • Tab for Pending Orders:

    • Manage Orders.

  • Accessing Facesheet for Patient:

    • Click patient, show reports at bottom of the Trackboard, and search for "Facesheet".

  • Accessing On Call List:

    • Open Google Chrome, go to THR homepage, select your location, and choose ED On Call Schedule from the menu.

Pharmacy Management

  • Changing Pharmacy Information:
    • Manage within the Dispo tab.

Printing Results

  • Printing Lab or Radiology Results:
    • View patient, check Rad Results and Lab Results (search), right-click, and print.