EPIC SmartPhrases for Chart Review & Problem List Updates
You may use these to help CCS and SCs in reviewing their patient's charts and providing common advice on certain problems.
Prediabetes: Copy and paste the below smart phrase, name it what you want. Exists in Paloma Orozco Scott's phrases as "PREDIABETESPROBLEMLIST"
[ ] Discuss diet --> update problem list
[ ] Discuss exercise --> update problem list
[ ] Explain how exercise decreases blood glucose levels
[ ] Explain how the A1C lab works and what it measures
[ ] Offer nutrition consult --> document if offered and why rejected
[ ] Annual A1C - DUE *** (make appointment with Cms)
See last A1C here Delete after inputting next due A1C check
Obstructive Sleep Apnea: Copy and paste the below smart phrase, name it what you want. Exists in Paloma Orozco Scott's phrases as "OSAPROBLEMLIST"
[ ] Update BMI (input height + weight in rooming)
[ ] Nutrition consult - offer and document if following or if declined
[ ] Enhanced STOP-BANG (search UpToDate for questions)
[ ] ROS for obstructive sleep apnea (OSA) - daytime sleepiness(hypersomnolence), waking up gasping for air or choking, early morning headaches
[ ] Depending on sx, discuss with attending if patient should have polysomnography or home sleep apnea test ( HSAT) to test for OSA. ------According to UpToDate patient's with high pre-test probability may be suitable candidates for HSAT with the correct device.
Dyspepsia Alarm Symptoms: Copy and paste the below smart phrase, name it what you want. Exists in Paloma Orozco Scott's phrases as "DYSPEPSIAALARMSYMPTOMSPROBLEMLIST"
Patient has a hx of dyspepsia / epigastric pain, this has a broad differential. Be sure to comment upon the following alarm symptoms in the problem list.
[ ] unintentional weight loss
[ ] dysphagia (difficulty swallowing)
[ ] odynophagia (painful swallow)
[ ] unexplained iron deficiency anemia
[ ] persistent vomiting
[ ] palpable mass or lymphadenopathy
[ ] family hx of upper GI cancer
Obesity: Copy and paste the below smart phrase, name it what you want. Exists in Paloma Orozco Scott's phrases as "OBESITY"
BMI Hx: ? @BMI@
Diet Hx: ?
Exercise Hx: ?
Family Hx Obesity: ?
Prior to your visit consult the EHHAP page on obesity medicine "https://ehhapp.org/obesity"
[ ] Review pts chart for possible etiologies/medications that contribute to weight gain
[ ] Always record height, weight, and BP in rooming during visits
[ ] Ask the patient if they are comfortable discussing their weight with you
[ ] Take a full diet, exercise, weight hx and summarize above
- Screen for behavioral conditions / eating disorders - Night eating - Cravings - Emotional eating "Do you feel a loss of control?" - Hx of anorexia, bulimia, or binge eating? - 24h food recall - What liquids does the patient drink? - When do they get hungry throughout the day? - Do they have $ for access to fresh foods - What is their baseline weight? - What is their heaviest weight?
[ ] Set a goal weight and/or or goal waist circumference. Goal of female 35 inches (88.9 cm). If patient prefers a goal weight help them obtain a scale.
[ ] Screen for obesity comorbidities
- HTN - T2D - Dyslipidemia - Sleep apnea [STOP-BANG calculator
[ ] Family hx of obesity
[ ] Consider if patient needs T2D screening if BMI >=25, Age 35-70
[ ] Discuss mediterranean diet with patient
[ ] Discuss utility of cutting down on carbohydrates (Dorans et al 2022 JAMA, low carb diet reduced A1C by 0.23% as compared to normal diet)
[ ] Obesity link with cardiovascular disease and hormonal cancers (endometrial, esophageal adenocarcinoma, colorectal, postmenopausal breast, prostate, and renal)
[ ] Ask if pt saw nurse educator for diet consultation
[ ] Offer nutrition consult, document if/when declined
FIB4 Score (Liver): Copy and paste the below smart phrase, name it what you want. Exists in Paloma Orozco Scott's phrases as "FIB4PROBLEMLIST"
Update Healthcare Maintenance with FIB-4 if available If patient has diabetes -or- prediabetes (A1C 5.7-6.4%) -or- obesity you can order CBC + Liver Fxn Panel If patient has no risk factors for liver disease then do not order labs to complete a FIB4
If score>1.4 1. fill out the ancillary clinic referral form for liver clinic https://forms.gle/7u2W4U7WEYwpM7nN9
FIB-4 INTERPRETATION (If 1.3 Epic message Liver TS, see roster) • If < 1.3 low likelihood of significant fibrosis at this time. Can be followed by primary care. Recommend fibrosis assessment every 2-3 years unless change in clinical status. • If > 1.3 Recommend FIBROSCAN referral. Patient will automatically be referred to hepatology if fibroscan suggestive of significant fibrosis.
Complete HTN history / workup
[ ] Duration: last normal BP, highs
[ ] Treatment: summarize med hx
[ ] Family HX: HTN, premature cardiovascular disease/death, kidney disease, diabetes, gout
[ ] Symptoms of secondary causes: muscle weakness, tachycardia, sweating, tremor, thinning of skin, flank pain
[ ] Symptoms of target-organ damage: headache, transient weakness/blindness, loss of visual acuity, chest pain, SOB, claudication
[ ] Risk factors: smoking, diabetes, dyslipidemia, physical inactivity, obesity, insufficient sleep (<7h a night), social determinants of health (food, housing, safety...ect)
[ ] Diet Hx: Na+, processed foods, alcohol, saturated fats
[ ] Psychosocial factors: family structure, work status, educational level.
[ ] Sexual function [males]
[ ] Etiology
[ ] Medicines causing secondary HTN: estrogen-OCPs, chronic use NSAID, antidepressants (MAO, SSRI, tricyclic), steroids, chronic use phenylephrine, EPO, Na+ containing antacids, stimulants, clozapine/olanzapine, TKIs)
[ ] Conditions causing secondary HTN: Primary kidney disease, obstructive sleep apnea (STOP-BANG score), Cushing's
[ ] Hx of Complications of HTN: LVH, Heart failure, stroke, intracerebral hemorrhage, MI, CKD/ESKD
New HTN Tests
[ ] CMP
[ ] Fasting glucose
[ ] UA
[ ] CBC
[ ] TSH
[ ] Lipids
[ ] ECG
[ ] ASCVD risk score
PENDING/ DESIRED SMARTPHRASES
- Back Pain
- Vit D Deficiency
- Joint Pain