Quality Measures Reporting Guide. Volume 2. Epic Clinical Documentation

Primary Care Improvement Collaborative (PCIC) Quality Measures Reporting Guide Volume 2 FY 2018 Epic Clinical Documentation

Table of Contents Attribution Methodology... 3 PCIC Measures Quality Measure Status Report in Epic@UNC... 4 My Patient Panel Report... 5 Quick Guide To Measure Exclusions... 7 ASCVD: Use of Aspirin or Another Antithrombotic... 9 Breast Cancer Screening... 10 Cervical Cancer Screening... 12 Colorectal Cancer Screening... 14 Depression Treatment... 17 Diabetes: A1C Poor Control >9.0%... 19 Diabetes: Eye Exam... 21 Hypertension: Blood Pressure Control... 23 Pneumococcal Vaccine Age 19-64 Chronic Conditions/Smokers... 24 Pneumococcal Vaccine 65+... 26 Statin Use... 28 Time to Third... 33 MyUNC Chart Activation... 35 Depression Screening (Watch Measure)... 36 Depression Remission (Test Measure)... 38 Falls Risk Assessment (Watch Measure)... 39 Influenza Immunization (Test Measure)... 41 Documentation for Exclusions... 43 Creating an Abstract Encounter... 46 Adding or Customizing Activity Tabs... 47 Page 2 of 47

Attribution Methodology Provider Level Data All patients seen for an office visit, clinical support visit, or patient outreach at a Primary Care (Family/Internal Med/Geriatrics or OB/GYN) practice in the past 18 months who have a specified UNC Provider listed as their PCP-General in Epic. Patients are attributed to their PCP-General Patients will ONLY be attributed to one provider Department Level Data Patients are attributed to their PCP-General s Primary Department Patients will ONLY be attributed to one department Practice Practice PCIC Page 3 of 47

PCIC Measures Quality Measure Status Report in Epic@UNC Clinic staff, care managers, and providers can run the PCIC Measures Quality reports that will show patients seen in an Internal Medicine, Family Medicine, or Geriatrics practice in the last 18 months, who are 18 years and older, and their associated quality measures. Action can be taken directly from the reports to help improve the quality measures. These Reporting Workbench reports provide nearly real-time data and can be run on demand (changes in some data may take up to one week to refresh on the report). PCIC Measures-My Department s Quality Measure Status report looks at patients who have a PCP in your login department. PCIC Measures-My Patients Quality Measure Status report will run for patients for whom you are on the patient s care team. For more information, review the Tip Sheet for PCIC Measures My Department s Quality Measure Status Report & PCIC Measures My Patient s Quality Measure Status Report here. NOTE: Do not be alarmed if there are slight differences in the Epic based reports and the PCIC Dashboard. For the PCIC Dashboard, performance represents patients attributed to one provider based on the PCP-General Field. For the Epic Report, performance represents patients who are associated with any Care Team member including the PCP-General and is run in real time. Therefore, it is possible in the Epic based report patients performance could be represented in more than one provider s metric calculation. Page 4 of 47

My Patient Panel Report Ensure you are correctly assigned as the PCP General. Running the report: 1. Click the Epic button on the top left, scroll down to Reports, and choose My Reports. 2. Click on the Library. 3. Type My Patient Panel in the search box, and press Enter. 4. Hover your mouse over the My Patient Panel report. a. If you are running this report for yourself, click Run. b. If you are running this report for a provider, click Edit. Select the criteria Run As User & Change to And; Enter your Provider s name 5. Click Save As to save your report settings for the future. 6. Name your report and click Accept. 7. Click Run. Page 5 of 47

Using the My Patient Panel report: 1. Click the Last Appt With Me column header to sort. a. Sorting on the patient s last appointment with you will help to determine if the provider should still be the PCP or the PCP field needs to be updated. Some things to consider: i. If the provider has never seen the patient since Epic, it will be blank. ii. If the provider hasn t seen the patient since 2014, is that provider still their PCP General? iii. If the provider has seen the patient once and someone else has seen the patient three times, which provider should be the PCP General? iv. If PCP column does not show the provider s name, it means the provider is on the Care Team, but not listed as the PCP General. Should the provider still be on the patient s Care Team? v. Use the PCP Attributed column to see the suggestion for who should be the PCP General. 2. Double-click on a patient s name to enter their chart to gather more information. 3. To remove or change the provider in the PCP General field or on the Care Team: a. Click PCP in the Patient Header. b. To remove: find the appropriate provider and click End. You may enter a comment about why you are making the change. c. To add: click Add in the appropriate field and enter the correct provider name. d. Click Accept. Page 6 of 47

Quick Guide To Measure Exclusions Measure **Exclusions included in ALL measures** Exclusion Criteria HM Modifier: Comfort Care Only Terminal Illness/Hospice Diagnosis ASCVD Aspirin Breast Cancer Screening Cervical Cancer Screening Colorectal Cancer Screening Depression Management Diabetes A1C Control > 9.0% Diabetes Eye Exam Hypertension: Blood Pressure Control Pneumococcal Vaccine Chronic Conditions Allergy/Adverse Reaction/Contraindication/Intolerance: Aspirin or Salicylate, or anticoagulant medication on active medication list HM Modifier: Not a candidate for mammograms HM Modifier: Bilateral Mastectomy Diagnosis/Procedures: Bilateral Mastectomy OR two Unilateral Mastectomies HM Modifier: Not a candidate for cervical cancer screening HM Modifier: Total Hysterectomy (No Cervix) Surgical History: Total/Radical Hysterectomy HM Modifier: Not a candidate for colon cancer screening Diagnosis/Procedures: Total Colectomy HM Modifier: Comfort Care Only Diagnosis: Add Terminal Illness/Hospice diagnosis to problem list HM Modifier: Not a candidate for routine hemoglobin A1C Testing HM Modifier: Not a candidate for Annual Dilated Retina Exam Diagnosis: End stage renal disease (ESRD), Chronic Kidney Disease (CKD) Stage 5, long-term dialysis, renal transplant, pregnancy Lab Value: Most recent GFR 15 HM Modifier: Not a candidate for Pneumococcal vaccine Allergy/Adverse Reaction/Contraindication/Intolerance: PNEUMOC 13-VAL CONJ-DIP CR(PF), PNEUMOCOCC 13- VALCONJ-DIP CRM, PNEUMOCOCCAL 23-VAL P-SAC VAC, PNEUMOCOCCAL 23-VALPS Vaccine, or Pneumococcal Vaccine Diagnosis: Pregnancy HM Modifier: Not a candidate for Pneumococcal vaccine Pneumococcal Vaccine 65+ Allergy/Adverse Reaction/Contraindication/Intolerance: PNEUMOC 13-VAL CONJ-DIP CR(PF), PNEUMOCOCC 13-VAL CONJ-DIP CRM, PNEUMOCOCCAL 23-VAL P-SAC VAC, PNEUMOCOCCAL 23-VALPS Vaccine, or Pneumococcal Vaccine Page 7 of 47

Diagnosis: Pregnancy ASCVD Prevention and Treatment Statin Measure Time to Third My UNC Chart Depression Screening (Watch Measure) Depression Remission (Test Measure) Falls Risk Screening (Watch Measure) Influenza Immunization (TEST Measure) Allergy: Drug group or specific statin HM Modifier: Not a candidate due to potential for pregnancy Diagnosis: End stage renal disease (ESRD), Chronic Kidney Disease (CKD) Stage 5, pregnancy Labs: LDL < 70 (for diabetes patients only without prior ASCVD), Most recent GFR 15 Exclusion Criteria NONE NONE HM Modifier: Not a candidate for Depression Screening HM Modifier: Cognitive Impairment Diagnosis: Schizophrenia, Schizotypal Personality Disorder Problem List: V46.3, Z99.2 Wheelchair Dependence or confined to bed or bedridden HM Modifier: Not a candidate for flu vaccine Allergy/Adverse Reaction/Contraindication/Intolerance: Influenza Virus Vaccine or any component of the vaccine *This measure does not exclude patients with Hospice/Terminal Illness or HM Modifier of Comfort Care Only Page 8 of 47

ASCVD: Use of Aspirin or Another Antithrombotic Denominator: This metric calculates the percentage of patients 18 who have a prior or existing diagnosis of ASCVD. Prior ASCVD events include a heart attack or stroke/tia, procedures include CABG or PCI/angioplasty, and diagnoses include angina, peripheral vascular/artery disease, coronary atherosclerosis, ischemic heart disease, cerebrovascular disease. Numerator: Patients who currently have an aspirin or an oral antiplatelet on their medication list (Clopidogrel, Prasugrel, Ticagrelor, Aspirin/Dypyridamole) Exclusions: Add a HM Modifier: Comfort Care Only Add an Allergy/Adverse Reaction/Contraindication/Intolerance: Aspirin or Salicylate, or anticoagulant medication on active medication list, Add Terminal Illness/Hospice diagnosis to problem list More information can be found on documenting exclusions on page 43. If patient is not already taking aspirin therapy (and it is appropriate to start): 1. Click the Plan Tab or Visit Navigator activity, and click Meds & Orders. 2. In the search box, type aspirin, and press Enter. Double-click the option you want. Click on the medication hyperlink to change order details. Change order details as needed. Click Accept. Associate a diagnosis to the order. Sign the order. If patient is already taking aspirin therapy: 1. Record the aspirin on the medications list: a. Click the Rooming Tab or Visit Navigator activity, and click Medications. b. In the search box, type aspirin, and press Enter. Double-click the medication the patient is taking. Fill out as much information about the medication as the patient can tell you, including dose, frequency, when they last took the medication, etc. Click Accept. c. After reviewing the medications the patient is taking, click Mark as Reviewed. Page 9 of 47

Breast Cancer Screening Denominator: Women, age 50 74, seen in the last 18 months; Numerator: Women who had one or more mammograms in the last 24 months Exclusions: Add a HM Modifier: Not a candidate for mammograms, Bilateral Mastectomy, or Comfort care only Add surgical history: Bilateral mastectomy or for whom there is evidence of two unilateral mastectomies Add Terminal Illness/Hospice diagnosis to problem list More information can be found on documenting exclusions on page 43. If ordering a mammogram: 1. Click the Plan tab or the Visit Navigator activity, and click Meds & Orders 2. In the search box, type mammogram, and press Enter. Double-click the option you want. Click the test hyperlink to change order details. Change the order details as needed. Click Accept. Associate a diagnosis to the order. Sign the order. Note: When ordering a mammogram, the default Expected Date is a year from the day you are ordering it, with the Expiration Date set to two years from the day you are ordering it. This means the patient is not meant to get the test done until next year. If you want the patient to have the test done sooner, change the Expected Date. 3. You can add a mammogram order to your Preference List and set the default of the Expected Date and Expiration Date to fit your preference without having to change the dates with each order. When creating the order in the Preference List, S means same day. S will be the day you are ordering the test. If you leave Expected as S, when you order it, it will have today s date. Page 10 of 47

If patient had a mammogram at an outside facility: 1. To get the proper tools, you must be in an encounter. If it is outside of the normal Office Visit, you may create an Abstract encounter, please refer to page 46. 2. Click on the Enter/Edit Results activity on the left. 3. In the toolbar at the top, towards the right, click Ext Result. (*Note: You will not see this option if you are not in an encounter.) 4. Click the + to open HM Procedures. Check HM MAMMOGRAPHY, and click Accept. 5. On the bottom half of the screen, click the Impression tab. This tab is used to document the results from the report or comments such as See scanned document. 6. Use the Results Routing section to send a results message to the PCP/other Care Team members. 7. On the bottom right, in the Result Section: a. Date: Enter the date that the procedure was PERFORMED (*Note: It will default to today s date and must be changed.) b. Time: This should be left BLANK c. Abnormal: Enter either Normal or Abnormal based on the results, if within your scope of practice d. Status: This should be Final 8. If you have the result to scan (which is preferred), continue below: (This step is usually done by support staff.) 9. To scan the results, in the toolbar, click Scan Results. 10. Use the Document Data section on the right to enter information about the scanned image. a. Description: Enter Procedure type and date performed b. Doc type: Choose Mammography 11. Verify that the result is for the selected patient. Load the document into the scanner top down, face down. Click Acquire. 12. Click Save doc from the toolbar. Click Accept. 13. If you do not have the results to scan, click Accept. The actual result is required for governmental measures. Please use the UNCH AMB HIPAA Request in Epic, or use the new Health Maintenance Central Records Request order available in Epic to obtain these results. A patient signature is no longer required for these Health Maintenance items. If the results are not received via in basket the support staff should scan to the order, follow scan steps below in step 14. 14. Go to Enter/Edit Results. Click Filter on the top left. a. Click All Order Types/Statuses and remove the dates or Click reset. Click Accept. b. Click the Test column header to sort A Z. Find the appropriate HM order and double-click it. c. Follow the same scan steps above starting with step 9. Page 11 of 47

Cervical Cancer Screening Denominator: Women, age 21 65 seen in the last 18 months; Numerator: Women age 21-29 who had a pap smear completed in the past 3 years. Women age 30-65 with either 1) a pap smear completed in the past 3 years or 2) a pap smear and HPV testing completed in the past 5 years Exclusions: Add a HM Modifier: Not a candidate for cervical cancer screening, Total Hysterectomy (No Cervix), or Comfort care only Add surgical history: Total Hysterectomy or Radical Hysterectomy. Documentation must include Total/Radical to be included. Add Terminal Illness/Hospice diagnosis to problem list More information can be found on documenting exclusions on page 43. If ordering cervical cancer screening: 1. If using the Standard view, click the Visit Navigator activity. If using widescreen, click on the Plan tab and click Meds & Orders. 2. In the search box, type pap and/or HPV, and press Enter. Double-click the option you want. Click the test hyperlink to change order details. Change order details as needed. Click Accept. Associate a diagnosis to the order. Sign the order. If patient had cervical cancer screening at an outside facility: 1. To get the proper tools, you must be in an encounter. If it is outside of the normal Office Visit, you may create an Abstract encounter, please refer to page 46. 2. Click on the Enter/Edit Results activity on the left. 3. In the toolbar at the top, towards the right, click Ext Result. (*Note: You will not see this option if you are not in an encounter.) 4. Click the + to open HM Procedures. Check HM PAP SMEAR and/or HPV, and click Accept. (*Note: Both the Pap Smear and HPV must be documented separately to satisfy Health Maintenance if the patient is on a Pap with HPV HM plan.) 5. On the bottom half of the screen, click the Impression tab. This tab is used to document the results from the report or comments such as See scanned document. Page 12 of 47

6. Use the Results Routing section to send a results message to the PCP/other Care Team members. 7. On the bottom right, in the Result Section: a. Date: Enter the date that the procedure was PERFORMED (*Note: It will default to today s date and must be changed.) b. Time: This should be left BLANK c. Abnormal: Enter either Normal or Abnormal based on the results, if within your scope of practice d. Status: This should always be Final 8. If you have the result to scan (which is preferred), continue below: (This step is usually done by support staff.) 9. To scan the results, in the toolbar, click Scan Results. 10. Use the Document Data section on the right to enter information about the scanned image. a. Description: Enter Procedure type and date performed b. Doc type: Choose Pap Smear 11. Verify that the result is for the selected patient. Load the document into the scanner top down, face down. Click Acquire. 12. Click Save doc from the toolbar. Click Accept. 13. If you do not have the results to scan, click Accept. The actual result is required for governmental measures. Please use the UNCH AMB HIPAA Request in Epic, or use the new Health Maintenance Central Records Request order available in Epic to obtain these results. A patient signature is no longer required for these Health Maintenance items. If the results are not received via in basket the support staff should scan to the order, follow scan steps below in step 14. 14. Go to Enter/Edit Results. Click Filter on the top left. i. Click All Order Types/Statuses and remove the dates or click Reset. Click Accept. a. Click the Test column header to sort A Z. Find the appropriate HM order and double-click it. b. Follow the same scan steps above starting with step 9. Page 13 of 47

Colorectal Cancer Screening Denominator: Patients, age 50 75 seen in the last 18 months; Numerator: Patients screened for colorectal cancer with a Fecal Occult Blood Test (FOBT) or Fecal Immunochemical Test (FIT) completed within the past year, or Colonoscopy completed in past 10 years, or Flexible Sigmoidoscopy completed in the past 5 years, or a FIT-DNA Stool test completed in the past 3 years Exclusions: Add a HM Modifier: Not a candidate for colon cancer screening Patients with a diagnosis or past history of total colectomy Add Terminal Illness/Hospice diagnosis to problem list More information can be found on documenting exclusions on page 43. If ordering colorectal screening: 1. Click the Plan Tab or Visit Navigator activity, and click Meds & Orders from the table of contents. 2. In the search box, type the name of the colorectal screening you want to order, and press Enter. Double-click the option you want. Click the test hyperlink to change order details. Change order details as needed. Click Accept. Associate a diagnosis to the order. Sign the order. a. If ordering a Fecal Immunochemical Test (FIT), use order POC327. Page 14 of 47

If patient has colorectal screening from an outside facility: 1. To get the proper tools, you must be in an encounter. If it s outside of the normal Office Visit, you may create an Abstract encounter, please refer to page 46. 2. Click on the Enter/Edit Results activity on the left. 3. In the toolbar at the top, towards the right, click Ext Result. (*Note: You will not see this option if you are not in an encounter.) 4. Click the + to open either HM Procedures or HM Labs. Check the appropriate HM order, and click Accept. 5. On the bottom half of the screen, click the Impression tab. This tab is used to document the results from the report or comments such as See scanned document. 6. Use the Results Routing section to send a results message to the PCP/other Care Team members. 7. On the bottom right, in the Result section: a. Date: Enter the date that the procedure was PERFORMED (*Note: It will default to today s date.) b. Time: This should be left BLANK c. Abnormal: Enter either Normal or Abnormal based on the results, if within your scope of practice. d. Status: This should be Final 8. If you have the result to scan (which is preferred), continue below: (This step is usually done by support staff.) 9. To scan the results, in the toolbar, click Scan Results. 10. Use the Document Data section on the right to enter information about the scanned image. a. Description: Enter Procedure type and date performed b. Doc type: Choose Mammography 11. Verify that the result is for the selected patient. Load the document into the scanner top down, face down. Click Acquire. 12. Click Save doc from the toolbar. Click Accept. 13. If you do not have the results to scan, click Accept. The actual result is required for governmental measures. Please use the UNCH AMB HIPAA Request in Epic, or use the new Health Maintenance Central Records Request order available in Epic to obtain these results. A patient signature is no longer required for these Health Maintenance items. If the results are not received via in basket the support staff should scan to the order, follow scan steps below in step 14. 14. Go to Enter/Edit Results. Click Filter on the top left. i. Click All Order Types/Statuses and remove the dates, or click Reset. Click Accept. a. Click the Test column header to sort A Z. Find the appropriate HM order and double-click it. b. Follow the same scan steps above starting with step 9. Page 15 of 47

If the patient has returned FOBT cards to clinic: 1. While in an encounter (should be a Nurse Visit or Office Visit encounter) click on Enter/Edit Results. 2. The outstanding test should be waiting for you to document. Double-click to open it. 3. Follow the steps from section: If patient has colorectal screening from an outside facility, steps 2-11. Page 16 of 47

Depression Treatment Denominator: Patients in the Depression Registry, 18 and older with their most recent PHQ-9 score >9 in the past year; Numerator: Patients with an antidepressant on their medication list, patients who had a visit with psychiatry or behavioral health with in the UNCMH system in past 6 months or a documented external behavioral health visit date or psychiatry visit date in SmartForm in past 6 months. Exclusions: Add a HM Modifier: Comfort Care Only Add Terminal Illness/Hospice diagnosis to problem list More information can be found on documenting exclusions on page 43. 1. While in the patient s chart, click on the Doc Flowsheets activity on the left. 2. Complete the PHQ-9 Depression Scale flowsheet. To see the patient s most recent score, click on Last Filed or look at Synopsis. 3. If the score to the PHQ-9 is >9, order an antidepressant or a behavioral health/psychiatry referral, if appropriate: a. Go to Meds & Orders. In the search box, search for either an antidepressant, psychiatrist or behavioral health referral, and press Enter. Double-click the option you want. Associate a diagnosis to the order. Sign your order. Page 17 of 47

If the Patient is receiving depression treatment from an external provider: 1. To get the proper tools, you must be in an encounter. If it s outside of the normal Office Visit, you may create an Abstract encounter, please refer to page 46. 2. Select More (Activities) Quick Navigators Care Mgmt. 3. When the Care Management Form Opens, enter the information as reported by the patient. The date entered for External Psychiatrist or External Behavioral Health is used in the Depression Treatment Measure. Page 18 of 47

Diabetes: A1C Poor Control >9.0% Denominator: Patients, age 18 75 in the Diabetes Registry seen in the last 18 months; Numerator: Patients with a hemoglobin A1c result greater than 9% in the last year *For this measure a lower value is better since it is looking at patients with poor control* Exclusions: Add a HM Modifier: Comfort Care Only or Not a candidate for routine hemoglobin A1C testing Add Terminal Illness/Hospice diagnosis to problem list More information can be found on documenting exclusions on page 43. If ordering Hemoglobin A1c: 1. Click the Plan tab or Visit Navigator activity, and click Meds & Orders. 2. In the search box, type A1C, and press Enter. Double-click the option you want, collected in the clinic, in the lab, or by POCT. If your clinic has equipment that electronically downloads POCT results into EPIC, be sure to choose the POCT order appended with RN Obtain. Click Accept. 3. Before signing your order, ensure the lab order is entered correctly. Click on the hyperlink for the order you entered. Change the Status, Class, etc. as needed and click Accept. Associate a diagnosis to the order. Sign your order. 4. If the test will be performed in the clinic, staff should go to the Visit Orders report on the Schedule workspace to document collecting the specimen. Page 19 of 47

If patient has Hemoglobin A1c done at an outside facility: 1. To get the proper tools, you must be in an encounter. If it is outside of the normal Office Visit, you may create an Abstract encounter, please refer to page 46. 2. Click on the Enter/Edit Results activity on the left. 3. In the toolbar at the top, towards the right, click Ext Result. (*Note: You will not see this option if you are not in an encounter.) 4. Click the + to open HM Labs. Check the A1C, and click Accept. 5. On the bottom half of the screen, click the Impression tab. This tab is used to document the results from the report or comments such as See scanned document. 6. On the bottom left, in the Components tab: a. Under Specimen, enter the Collection date. This should be the day of the results. b. Under Components, enter the Value. (*Note: The Value field should only consist of numbers.) 7. Use the Results Routing section to send a results message to the PCP/other Care Team members. 8. On the bottom right, in the Result section: a. Date: Enter the date that the procedure was PERFORMED b. Time: This should be left BLANK c. Abnormal: Enter either Normal or Abnormal based on the results, if within your scope of practice d. Status: This should be Final 9. If you have the result to scan (which is preferred), continue below: (This step is usually done by support staff.) 10. To scan the results, in the toolbar, click Scan Results. 11. Use the Document Data section on the right to enter information about the scanned image. a. Description: Enter Procedure type and date performed b. Doc type: Choose Labs 12. Verify that the result is for the selected patient. Load the document into the scanner top down, face down. Click Acquire. 13. Click Save doc from the toolbar. Click Accept. 14. If you do not have the results to scan, click Accept. The actual result is required for governmental measures. Please use the UNCH AMB HIPAA Request in Epic, or use the new Health Maintenance Central Records Request order available in Epic to obtain these results. A patient signature is no longer required for these Health Maintenance items. If the results are not received via in basket the support staff should scan to the order, follow scan steps below in step 16. 15. Go to Enter/Edit Results. Click Filter on the top left. a. Click All Order Types/Statuses and remove the dates or Click reset. Click Accept. b. Click the Test column header to sort A Z. Find the appropriate HM order and double-click it. c. Follow the same scan steps above starting with step 9. Page 20 of 47

Diabetes: Eye Exam Denominator: Patients in the Diabetes Registry age 18-75; Numerator: Patients with a retinal eye exam in the past year or patients whose last retinal eye exam was in the last two years with a negative result (no retinopathy both eyes) documented *Retinal eye exam completed procedures include: fundus photography, fundus auto-fluorescence, OCT, fluorescein angiography, completion of periphery exam fields by Ophthalmology or HM Diabetes Eye Exam (with result).* Exclusions: Add a HM Modifier: Comfort Care Only, Not a candidate for annual dilated retina exam Add Terminal Illness/Hospice diagnosis to problem list More information can be found on documenting exclusions on page 43. If ordering an eye exam: 1. Click the Plan Tab or Visit Navigator activity, and click Meds & Orders. 2. Order a retinal eye exam/dilated eye exam, or a referral to an Ophthalmologist or Optometrist: *Note: If ordering a referral to an Ophthalmologist or Optometrist, ensure you reference the patient needing a retinal eye exam/dilated eye exam. a. In the search box, type the name of the test or referral you want to order, and press Enter. Double-click the option you want. Click on the order hyperlink to change order details. Change order details as needed. Click Accept. Associate a diagnosis to the order. Sign the order. If patient had exam done at outside facility records must be obtained before documenting external result: 1. The actual result is required for governmental measures. Please use the UNCH AMB HIPAA Request in Epic, or use the new Health Maintenance Central Records Request order available in Epic to obtain these results. A patient signature is no longer required for these Health Maintenance items. If the results are not received via in basket the support staff should scan to the order, follow scan steps below starting with step 2. Page 21 of 47

If patient brings results from outside facility: 1. To get the proper tools, you must be in an encounter, and must have the results in order to document. If it is outside of the normal Office Visit, you may create an Abstract encounter, please refer to page 46. 2. Click on the Enter/Edit Results activity on the left 3. In the toolbar at the top, towards the right, click Ext Result. (*Note: You will not see this option if you are not in an encounter.) 4. Click the + to open HM Procedures. Check HM DIABETIC EYE EXAM and click Accept. 5. On the bottom right, in the Result Section: a. Date: Enter the date that the procedure was PERFORMED (*Note: It will default to today s date.) b. Time: This should be BLANK 6. On the bottom left, in the Component Section: a. Value: THIS IS A HARD STOP. Click on the looking glass to select the correct choice based on the results, if within your scope of practice b. Status: This should always be Final 7. Click on the Impression tab to document where the eye exam was done. 8. Use the Results Message section to send a results message to the PCP/other Care Team members. 9. Go to Enter/Edit Results. Click Filter on the top left. a. Click All Order Types/Statuses and remove the dates, or click Reset. Click Accept. 10. Click the Test column header to sort A Z. Find the appropriate HM order and double-click it. 11. To scan the results, in the toolbar, click Scan Results. a. Use the Document Data section on the right to enter information about the scanned image. i. Description: Enter Procedure type and date performed ii. Doc type: Choose Diabetic Eye Exam b. Verify that the result is for the selected patient. Load the document into the scanner top down, face down. Click Acquire. Click Save doc from the toolbar. Click Accept. Page 22 of 47

Hypertension: Blood Pressure Control Denominator: Patients age 18-85 in the Hypertension Registry Numerator: Patients age 18-59 whose most recent ambulatory BP recorded in the past year where SBP is <140 and DBP is <90, patients age 60-85 whose most recent ambulatory BP recorded in the past year where SBP is <150 and DBP is <90 Exclusions: Add a HM Modifier: Comfort Care Only Add to the Problem List: chronic kidney disease (CKD) stage 5, end stage renal disease (ESRD), long-term dialysis, renal transplant, pregnancy, terminal illness, hospice care Most recent GFR 15 More information can be found on documenting exclusions on page 43. 1. Click the Rooming Tab or Visit Navigator activity, and click Vital Signs from the table of contents. 2. Document the patient s blood pressure. 3. If the Blood Pressure reading is elevated, have the patient sit for 5 minutes then recheck the BP and document the new reading under New Set of Vitals. Page 23 of 47

Pneumococcal Vaccine Age 19-64 Chronic Conditions/Smokers Denominator: Age 19-64 with one of the following chronic conditions: alcoholism, heart failure, chronic liver disease, COPD, diabetes or current smoker (according to social history) seen in the last 18 months; Numerator: Health Maintenance topic PNEUMOCOCCAL VACCINE is not "Due On" or "Overdue". (i.e. patient has received PPSV-23 vaccine according to CDC guidelines) Exclusions: Add a HM Modifier: Not a candidate for pneumococcal vaccine or Comfort care only Add an Allergy/Adverse Reaction/Contraindication/Intolerance: PNEUMOC 13-VAL CONJ-DIP CR(PF), PNEUMOCOCC 13-VAL CONJ-DIP CRM, PNEUMOCOCCAL 23-VAL P-SAC VAC, PNEUMOCOCCAL 23-VALPS VACCINE, or PNEUMOCOCCAL VACCINE Add to problem list pregnancy, terminal illness, or hospice More information can be found on documenting exclusions on page 43. If patient reports receiving a pneumonia vaccine: 1. If you are on the Schedule workspace: On the top half of the screen, click on the patient for whom you would like to enter information. On the bottom half of the screen, click on the SnapShot report. Click the hyperlink for Immunizations/Injections to go into the patient s chart to the Immunizations activity. If you are in the patient s chart: Click on the Immunizations activity on the left. If you do not see it, click More Activities on the bottom left, and choose Immunizations. (If you want to make Immunizations one of your activities, click More Activities and click the star icon next to Immunizations.) 2. Once in the Immunization activity, on the toolbar at the top click Historical Admins. a. Scroll down to the appropriate pneumococcal option and enter the date the patient reports receiving the pneumonia vaccine, which one was received (PCV 13 or PCV 23) and any additional information as needed. b. Click Accept. Page 24 of 47

If ordering and administering the Pneumonia vaccination during this encounter: 1. Click the Visit Navigator activity, and click Meds & Orders from the table of contents. 2. In the search box, type pneumo to get the option for the 13 or 23, and press Enter. Double-click the option you want. Click on the medication hyperlink to change order details. Sign the order. 3. Once the vaccine is ordered, the nurse will see a task on the schedule, as indicated by the blue dot. 4. On the report toolbar, click the Visit Orders report. Under the section Procedure Orders this Encounter, you will see the ordered vaccination with an Administer hyperlink. Click the Administer hyperlink to document administering the vaccine. 5. Click Administer next to the vaccine you are about to administer. a. Fill in hard stops, any additional information; answer the questions, and Click Accept. Page 25 of 47

Pneumococcal Vaccine 65+ Denominator: Patients, age 65 or older seen in the last 18 months; Numerator: Health Maintenance topic PNEUMOCOCCAL VACCINES is not "Due On" or "Overdue". (i.e. patient is up-to-date with CDC guidelines for receiving PPSV-23 and PCV-13.) This measure takes into account the time periods the patient must wait before receiving the next vaccine Exclusions: Add a HM Modifier: Not a candidate for pneumococcal vaccine or Comfort care only Add an Allergy/Adverse Reaction/Contraindication/Intolerance: PNEUMOC 13-VAL CONJ-DIP CR(PF), PNEUMOCOCC 13-VAL CONJ-DIP CRM, PNEUMOCOCCAL 23-VAL P-SAC VAC, PNEUMOCOCCAL 23-VALPS VACCINE, or PNEUMOCOCCAL VACCINE Add terminal illness, hospice or Pregnancy to problem list More information can be found on documenting exclusions on page 43. If patient reports receiving a pneumonia vaccine: 1. If you are on the Schedule workspace: On the top half of the screen, click on the patient for whom you would like to enter information. On the bottom half of the screen, click on the SnapShot report. Click the hyperlink for Immunizations/Injections to go into the patient s chart to the Immunizations activity. If you are in the patient s chart: 2. Once in the Immunization activity, on the toolbar at the top click Historical Admins. a. Scroll down to the appropriate pneumococcal option and enter the date the patient reports receiving the pneumonia vaccine, which one was received (PCV 13 or PCV 23) and any additional information as needed. b. Click Accept. Page 26 of 47

If ordering and administering the Pneumonia vaccination during this encounter: 1. From the Visit Navigator, click on Meds & Orders. 2. In the search box, type pneumo to get the option for the 13 or 23, and press Enter. Double-click the option you want. Click on the medication hyperlink to change order details. Sign the order. 3. Once the vaccination is ordered, the nurse will see a task on the schedule, as indicated by the blue dot. 4. On the report toolbar, click the Visit Orders report. Under the section Procedure Orders this Encounter, you will see the ordered vaccination with an Administer hyperlink. Click the Administer hyperlink to document administering the vaccine. 5. Click Administer next to the vaccine you are about to administer. a. Fill in hard stops, any additional information; answer the questions, and Click Accept. Recommendation from CDC on vaccine timeline: https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf CDC / ACIP Pneumococcal Vaccine in Adults with Certain Conditions CDC / ACIP Recommendation Pneumococcal Vaccine for Adults over age 65 https://www.cdc.gov/vaccines/vpd/pneumo/downloads/pneumo-vaccine-timing.pdf Page 27 of 47

Statin Use Denominator: The denominator is evaluated in this order: 1) Age 21 or older with prior ASCVD (see below) OR 2) Age 40-75 with 10-year ASCVD Risk > 10% OR 3) Age 40-75 in diabetes registry (*see below for exclusion if LDL<70) Prior ASCVD = - Events: diagnosis of heart attack or stroke/tia - Procedures: CABG or PCI/angioplasty - Diagnoses: angina, peripheral vascular/artery disease, coronary atherosclerosis, ischemic heart disease, cerebrovascular disease; Numerator: Patients who have a statin medication present on their medication list Exclusions: Add a HM Modifier: Comfort Care Only or Not a candidate due to potential for pregnancy Patients with a most recent LDL <70 Add an Allergy/Adverse Reaction/Contraindication/Intolerance: statin medication or the class of statin meds (HMG-CoA Reductase inhibitors) Patients with terminal illness or hospice diagnoses Patients who are pregnant, have ESRD or CKD stage 5 diagnoses or most recent GFR 15 Patients with diabetes (but not ASCVD) with last LDL <70 are also excluded from this metric For this measure, the numerator is calculated first, and then exclusions are taken out. Therefore, if a patient qualifies for exclusion but is on the medication, they will get credit for the measure More information can be found on documenting exclusions on page 43. The 10-year ASCVD Risk Calculator uses the data below to calculate the percent risk. If some pieces of data are missing or are beyond the range of the calculator (eg, HDL <20 or >100, total cholesterol <130 or >320, systolic BP <90 or >200), a risk cannot be calculated. The lookback period is 6 years for HDL and Total Cholesterol and 1 year for systolic blood pressure. Age Last HDL Last Systolic Blood Presence/absence of antihypertension Gender Last Total Cholesterol Pressure medication on active medication list Race Smoking Status Presence/absence in diabetes registry Documenting age, gender, and race: 1. Within the Demographics activity: a. Contact Information tab: Document age (birth date) and gender (sex): Page 28 of 47

b. Clinical Information tab: Document the race: Documenting blood pressure: 1. Click the Rooming Tab or Visit Navigator activity, and click Vital Signs. 2. Document the patient s blood pressure. Documenting smoking status: 1. Click the Rooming Tab or Visit Navigator activity, and click History. 2. Scroll down to the Social History subsection. Fill in the Tobacco Use. (can also navigate to this section from vital signs) Page 29 of 47

Last LDL and last total cholesterol: If ordering a LDL and total cholesterol: 1. Click the Plan Tab or Visit Navigator activity, and click Meds & Orders. 2. In the search box, type the name of the lab you want to order, and press Enter. Double-click the option you want. Click the test hyperlink to change order details. Change order details as needed. Click Accept. Associate a diagnosis to the order. Sign the order. NOTE: If you order a Lipid Panel, both Total Cholesterol and HDL are included. Page 30 of 47

If patient has labs from an outside facility and they have brought the documented results: 1. To get the proper tools, you must be in an encounter. If it s outside of the normal Office Visit, you may create an Abstract encounter, please refer to page 46. 2. Click on the Enter/Edit Results activity on the left. 3. In the toolbar at the top, towards the right, click Ext Result. (*Note: You will not see this option if you are not in an encounter.) 4. Click the + to open HM Labs. Check the appropriate lab (HDL Cholesterol and Total Cholesterol, or Lipid Panel), and click Accept. 5. For each lab you are recording, on the bottom half of the screen, click the Impression tab. This gives you the chance to document the impression from the report or See scanned document. 6. On the bottom left, in the Components tab: a. Under Specimen, enter to Collection date. This should be the day of the results. b. Under Components, enter the Value. (*Note: The Value field should only consist of numbers.) 7. Enter a Recipient the Results Message section to send a results message to the PCP/other Care Team members. 8. On the bottom right, in the Result section: a. Date: Enter the date that the procedure was PERFORMED b. Time: This should be BLANK c. Abnormal: Enter either Normal or Abnormal based on the results, if within your scope of practice d. Status: This should be Final 9. Scan the results. (This step is usually done by support staff.) a. In the toolbar, click Scan Results. b. Use the Document Data section on the right to enter information about the scanned image. i. Description: Enter Procedure type and date performed ii. Doc type: Choose Labs iii. Note Author: Click Author not in system c. Verify that the result is for the selected patient. Load the document into the scanner top down, face down. Click Acquire. Click Save doc from the toolbar. Click Accept. 10. After all scanning is complete, click Accept in Enter/Edit Results. Page 31 of 47

If patient is not already taking statin therapy: 3. Click the Plan Tab or Visit Navigator activity, and click Meds & Orders. 4. In the search box, type the name of the statin you want to order, and press Enter. Double-click the option you want. Click on the medication hyperlink to change order details. Change order details as needed. Click Accept. Associate a diagnosis to the order. Sign the order. If patient is already taking statin therapy: 2. Record the statin on the medications list: a. Click the Rooming Tab or Visit Navigator activity, and click Medications. b. In the search box, type the name of the medication, and press Enter. Double-click the medication the patient is taking. Fill out as much information about the medication as the patient can tell you, including dose, frequency, when they last took the medication, etc. Click Accept. c. After reviewing the medications the patient is taking, click Mark as Reviewed. Page 32 of 47

Time to Third Description: This metric calculates the number of calendar days between the date of measurement and the third available appointment for each new visit type and is averaged across the department. The average is weighted by the relative demand of each new visit type. Exclusions: There are no exclusions. 1. To review go to My Dashboard. 2. Click on Department Dashboard 3. Click on the Filter icon to find your department, located on the right side of the screen. 4. Filter down to your department by first selecting an Entity, then the Specialty, then the Department, then Run. (The Filter can also be used to review individual providers). 5. You will be able to review and see the trend in the graph. Page 33 of 47

Steps to improve this metric: 1. Ensure the waitlist is utilized to fill open slots from cancelled appointments. a. If slot not available for patient, from within the appointment desk go to wait list. Click Add and fill out hard stops and other pertinent information. b. If slot becomes available due to cancellation, go to waitlist, highlight the patient, and click schedule. 2. Identify providers with low projected utilization and direct agents to fill open slots by working the waitlist, working the referral workque, and/or moving up patients scheduled far out. 3. Review whether your staff are consistently following your departments scheduling guidelines relative to provider templates (i.e. overbook rates) and evaluate training concerns for staff members. Page 34 of 47

myunc Chart Activation Denominator: All patients, regardless of age, who had an office visit in the last 18 months at family medicine, internal medicine, geriatrics, or OB/GYN; Numerator: Patients with an active myunc Chart account on the last date of the month ** Patients are attributed to their PCP and that provider s primary department and can show up under multiple practices and entities. If a patient visits more than one practice in an entity, they only count once towards the entity but will count once towards each practice. This is the same for the system, patients will only show up only once as long as they had a visit that month.* Exclusions: There are no exclusions. 1. To view your my chart activation rates go to the Epic button, choose Reports, and then My Reports. and click on the library tab. 2. In the search box, type mychart. MyChart Activation Rates and MyChart Activation (Crystal) reports will be available. Click Run. If the patient agrees to sign up: 1. Go to MyChart Sign-up within the visit navigator. This will take you to another screen; follow prompts to sign patients up for mychart. Page 35 of 47

Depression Screening (Watch Measure) Denominator: Patients, age 18 years and older, seen in the last 18 months; Numerator: Patients screened for depression with a complete PHQ-2 with score of 0-2 in the past year, a complete PHQ-2 3 must be followed by a complete PHQ-9 in the past year, a complete PHQ-9 in the past year, or a complete Edinburgh (postpartum/pregnancy) screening in the past year Exclusions: Add a HM Modifier: Comfort Care Only or Cognitive Impairment or Not a Candidate for Depression Screening Add terminal illness or hospice to problem list More information can be found on documenting exclusions on page 43. Depression screening can be completed real-time using Doc Flowsheets or you could have the patient complete a paper PHQ screening and transfer the data into Doc Flowsheets. 1. While in the patient s chart, click on the Flowsheets activity on the left. 2. Start with the PHQ-2 Depression Screen flowsheet. a. If the total score for the first 2 questions is 0, 1 or 2, the screening is complete. b. If the total score for the first 2 questions is 3 or greater, complete the PHQ-9 screening. 3. If the total score for the PHQ-2 is 3 or greater, complete the PHQ-9 Depression Scale flowsheet. 4. If the patient answers yes to Thoughts that you would be better off dead, or of hurting yourself in some way, ask the patient Have you had thoughts of actually hurting yourself? 5. If the patient answers Yes, inform the provider, who will complete the P4 Suicidality Screener flowsheet. Page 36 of 47

The Suicide Risk Screening: Positive response BPA must be satisfied for it to go away by either: o Open the SmartSet and document the Suicide Risk Assessment Documentation or o Complete the P4 Suicide Risk Screen The Edinburgh/Postpartum tools within Epic will also satisfy the depression screening. Note: Both the Edinburgh and Postpartum Depression tools are the same questions in Epic. Some providers will have the Postpartum Depression flowsheet automatically; either can be used for this measure. 1. While in the patient s chart, click on the Flowsheets activity on the left. 2. If you do not have the Edinburgh flowsheet already available you will need to add it to your flowsheets. 3. To add a flowsheet, click on the magnifying glass on the far right. 4. Type in Edinburgh in the search bar, enter, and then click on the Facility Pref List. Once you have made your selection, click Accept. 5. You will then document in the flowsheet accordingly. Page 37 of 47

Depression Remission (Test Measure) Denominator: All patients age 18 and older in the Depression Registry with an index PHQ-9 >9 in the past 18 months; Numerator: Patients who have achieved remission (PHQ-9 score <5) 1-15 months after the index PHQ-9 score Exclusions: Patients with schizophrenia, schizotypal personality disorder, hospice care/terminal illness diagnoses, HM modifier 'comfort care only' or with 'residence in long term care facility' on problem list are excluded from this metric More information can be found on documenting exclusions on page 43. 1. To view a patient s PHQ trends, the Synopsis can be used. While in the patient s chart, click on the Synopsis activity and select the Depression tab. The timeframe displayed defaults to 6 months, however you can choose a longer period from the dropdown to the right. 2. Then click on Depression, the PHQ-9 scores and graph are shown with dates. Page 38 of 47

Falls Risk Assessment (Watch Measure) Denominator: Patients, age 65 and older at visit, seen in the last 18 months back; Numerator: Patients who were screened for future fall risk at least once in the last year Exclusions: Add a HM Modifier: Comfort Care Only Add to the Problem List: Wheelchair Dependence (V46.3, Z99.3) More information can be found on documenting exclusions on page 43. 1. Click the Visit Navigator activity, and click Fall Assessment from the table of contents. If using the Widescreen view, click the Rooming activity, and click Fall Assessment from the top of the screen. 2. The Fall Assessment section will appear in the Visit Navigator for patients age 18 or older who have not had a Fall Assessment completed in the past 11 months. 3. If a patient is age 65 or older and has not had a Falls Assessment completed in the past 11 months, an alert banner will display in the Risk Assessments section to indicate an annual falls assessment is due. To meet the measure, a falls risk must be charted at least once per year. 4. The Fall Risk Assessment contains two questions. A positive response to either of the questions indicates that the patient is at an increased risk for falls. Document Yes or No to the two questions. If a previous assessment has been completed, that information is also displayed. To document a positive falls assessment, follow the steps below. 5. The Falls Assessment positive Best Practice Advisory (BPA) will fire if the assessment indicates that the patient is at increased risk for falls (by either question being answered yes ), alerting the provider to take action. If a patient screens positive, documenting interventions and a plan of care is the action required to turn off the BPA. The BPA will continue to fire across encounters in ALL departments, until action is taken to address the falls risk. a. Select the boxes to indicate which actions you want to take: Page 39 of 47

Select Open SmartSet : o Select the appropriate interventions and documentation by clicking in the box to the left of your selection. Place orders and referrals as needed. Click on a Summary Sentence next to an order to specify patient-specific details as appropriate. o Select the Falls Assessment Positive and the SmartList will be placed in your note. Press F2 and complete the SmartList to indicate the interventions taken, then click Accept. NOTE: The system SmartPhrase.FALLSPOSITIVE is also accessible in a Progress note or any Smart Tool enabled area outside of the Falls Assessment Positive SmartSet. o Sign the SmartSet Select Add to Problem List to add Risk for falls to the patient s Problem List. Only providers will add problems to the Problem List. Adding Risk for falls to the patient s problem list suppresses the BPA indefinitely. Select the Goal Initiate: Add new patient goal: prevent falls to document a fall prevention goal for the patient. Once the goal is added, it is recommended that specific actions be listed and discussed with the patient. Adding the goal will suppress the BPA for 12 months. Select an Acknowledge reason : o Delay Other clinical priorities: suppresses the BPA for 12 hours Click the Timed Up and Go (TUG) link to document TUG results in a flowsheet. This does not satisfy the BPA. b. Scroll to the bottom of the BPA section and click Accept to confirm your selections. Page 40 of 47

Influenza Immunization (Test Measure) Denominator: Patients age > 6 months old; Numerator: Patients who have a documented Flu Vaccine administered in the current flu season (August 1- March 31) according to HM topic Exclusions: Add a HM Modifier: Not a candidate for influenza vaccine Add an Allergy/Intolerance: Influenza Virus Vaccine or any component of the vaccine More information can be found on documenting exclusions on page 43. If patient reports receiving an Influenza vaccine elsewhere: 1. If you are on the Schedule workspace: On the top half of the screen, click on the patient for whom you would like to enter information. On the bottom half of the screen, click on the SnapShot report. Click the hyperlink for Immunizations/Injections to go into the patient s chart to the Immunizations activity. 2. If you are in the patient s chart: Click on the Immunizations activity on the left. 3. Once in the Immunization activity, on the toolbar at the top click Historical Admins. a. Scroll down to bottom of the immunization list to a blank section and type in influ and then click the looking glass to pull up a list of influenza vaccines, choose the correct one and enter the date the patient reports receiving the influenza vaccine and any additional information as needed. b. Click Accept. Page 41 of 47

If ordering and administering the Influenza vaccination during this encounter: 4. Click the Visit Navigator activity, and click Meds & Orders from the table of contents. 5. In the search box, type influ to get the option for the patient age and vaccine type, and press Enter. Double-click the option you want. Click on the medication hyperlink to change order details. Sign the order. 6. Once the vaccine is ordered, the nurse will see a task on the schedule, as indicated by the blue dot. 7. On the report toolbar, click the Visit Orders report. Under the section Procedure Orders this Encounter, you will see the ordered vaccination with an Administer hyperlink. Click the Administer hyperlink to document administering the vaccine. 8. Click Administer next to the vaccine you are about to administer. a. Fill in hard stops, any additional information; answer the questions, and Click Accept. Page 42 of 47

Documentation for Exclusions WHY?: For Quality Reporting metrics, Merit-based Incentive Payment System (MIPS), Primary Care Improvement Collaborative (PCIC), etc.), it is CRITICAL that providers capture data in a structured format in Epic@UNC. This quality data is a fundamental foundation in regard to ensuring EHR records are complete and accurate, which in turn, allows for improved patient care. Documenting Allergies, Intolerances, Contraindications, and Adverse Reactions: 1. While in the patient s chart, in the Patient Header at the top of the screen, click Allergies. 2. Type in the name of the allergy. (NOTE: Using the name of the medication is the preferred method. If you are not aware of the medication the patient is allergic to, you can type the name of the drug class. For example Lisinopril would be preferred over ACE Inhibitor.) Press enter. Double-click the allergy you would like to add. a. Fill out as much information about the allergy as the patient can tell you and click Accept. i. Reactions: Fill in one reaction per cell. If you do not see what you are looking for, choose Other (See Comments) and enter it in the comments box on the right. ii. Reaction type: Choose Adverse Reaction (Not otherwise classified), Allergy, Contraindication, or Intolerance. b. After reviewing the allergies the patient has, click Mark as Reviewed. (Allergies with a High Severity will be highlighted in yellow.) Page 43 of 47

Documenting Diagnoses on the Problem List: 1. Click on the Problem List. 2. Type in the diagnosis or diagnosis code and press Enter. Double-click the diagnosis you would like to add. Enter information as appropriate and click Accept. Documenting History in the History Activity: 1. Click the Visit Navigator activity, and click History from the table of contents. 2. Document patient s history in the Medical History and Surgical History sections. Click Yes next to the appropriate entry. If you cannot find what you are looking for, use the search box in each section: Documenting Patient Refuses/Declines or Urgent/Emergent Situations: These types of exclusions rely on clinical documentation in progress notes; however, this information may not be reportable without manual chart abstraction. Using Health Maintenance Modifiers: Health Maintenance Modifiers are used to tailor health maintenance to be patient specific. Health Maintenance modifiers can also be used to include or exclude a patient from reporting. 1. While in the patient s chart, click Health Maintenance from the Patient Header at the top of the screen, or from the side navigator. Once in the Health Maintenance activity, click Edit Modifiers in the toolbar at the top. Page 44 of 47

2. Search for Not a Candidate. 3. Select the appropriate modifier and click Accept. *Note: Use Comfort Care Only if your patient is on comfort care. This will remove the patient from all topics (except flu) and outreach. 4. You will then see the entry in the HM Modifiers sectionof the Health Maintenance activity: 5. Click Update HM on the Health Maintenance Toolbar. Page 45 of 47

Creating an Abstract Encounter If you need to document external results outside of an Office Visit encounter, you may create an Abstract encounter. 1. Click on the Epic button on the top left. Scroll down to Patient Care and choose Encounter. 2. Search for the appropriate patient. 3. A new window will open. On the bottom left, click New. 4. The New Encounter window opens. a. Date: This should be the date you are creating the Abstract encounter b. Type: Choose Abstract c. Provider: This should be the person creating the encounter. This will show up in Chart Review and you will be able to see who created the encounter d. Department: This should be the department where the Abstract encounter is being created 5. Click Accept. 6. You are now in the Abstract encounter. 7. When you are done with your documentation, be sure to close the encounter. Click Visit Navigator and choose Sign Visit to close the encounter. Page 46 of 47

Adding or Customizing Activity Tabs If you need to add an activity tab for documentation or if you need to re-organize your tabs for ease of use. If you would like to add a tab to your side navigator that is not already included, for example, Immunizations follow the steps below: 1. Click More on the bottom left, and choose the item you would like to add. For this example Immunizations was used. 2. Click the star icon next to the item you would like to add. 3. You will then see the icon in your side navigator. 4. If you want to customize the toolbar, click Customize on the bottom left column, then you can drag, drop and rearrange items where you want them in the toolbar. Page 47 of 47