Policy/Guideline Linking

  • Guidelines and protocols will be linked as PDF’s. If the team makes changes, place a WF request to the Epic IT Orders team to have the PDF updated. The team requests a 3 week turn-around time to update the document.
    • If these are maintained by an entity council like EBP Advisory Council, Nursing Clinical Practice, or MS&T we will have to work this step into our processes after updates are approved (if they are linked to orders or order sets)
    • If these are maintained by units (i.e. PICU standards/protocols), I’m not sure who will do this yet but I’d imagine the unit representative?
    • I’m admittedly getting ahead of myself but I think as IT governance post go-live becomes more clear the update process will become more clear.
  • Policies will be linked via the PolicyStat link.
    • Policies are updated by Policy Oversight Committee and then updated in PolicySTAT, hence the link will remain constant and versions/edits can be tracked
  • Where to link in order set
    • Guidelines or protocols linked at the order set level are reference documents viewable only to the prescriber upon placing the order. These are references to assist in placing orders but the order details has everything needed to execute the order (Ex: Sepsis Guideline in Sepsis Order Set)
    • Guidelines or protocols linked at the orderable level are viewable to the RN/RT/caregiver when reviewing orders or acting upon protocol. These details are needed to make the order complete and actionable (Ex: PICU Oxygen Management Protocol)
    • Neither are viewable on the MAR where order sign off occurs
  • New location of policies as of 240508: \\epicshareprd\epicshareprd\Application_Domain_User_Access\IP_Orders\Order
Policy/Guideline Linking