[epicproviders] Epigram: Difficult Airway Documentation in Epic

[Epic - All Provider Staff]

Documenting Difficult Airway in Epic

An update to Epic planned for Monday, April 24, allows for improved documentation of patients with difficult airways. With documentation of a difficult airway, a new flag on the storyboard, "Airway Status: Difficult Airway", will appear in a red box to inform you that your patient has a known difficult airway.

How to document a difficult airway:
There are 3 ways to document that a patient has a difficult airway. All will create the flag in the storyboard. You can use the one that is most appropriate for you.

  1.  Documenting a difficult airway after intubation. Intubation procedure notes now have a section where you can indicate airway status.
  2.  Problem list. You can add a problem of "Difficult Airway" to the problem list. For most patients, you should also make this problem a "chronic" problem. This method is best for patients with physical findings or history indicative of a difficult airway.  It is also appropriate to add this problem after noting a difficult airway in an intubation note, however, the procedure note itself is enough to turn the flag on.
  3.  Patient FYI. The third option is to add a patient FYI of "difficult airway". Note that the first 2 options create the FYI automatically,
How to remove the difficult airway flag:
Should the patient no longer have a difficult airway, removing the flag by completing the difficult airway FYI is possible. This will remove the flag on the storyboard but will appropriately not remove clinical documentation in any prior intubation note.  If the problem list has an entry for "Difficult Airway" you should also complete it there, however, only removing the FYI clears the storyboard flag.

How to learn more:
I have attached the tip sheets for this process to this Epigram.
________________________________

>From the Desk of the CMIO

Neal Seidberg, MD

seidbern at upstate.edu

315-464-7507

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