Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 We know that not every physician works the same way; Cerner solutions allow for screen customization, allowing you to provide the best care with the fewest distractions. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. bilat UE/LE strength, no gross motor or sensory defects noted. They are aware of the suspected diagnosis suggested by screening exam, [_], based upon the initiated medical screening exam. We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. _, MDM Needlestick: Risks of CT radiation far outweigh any risks of intracranial hemorrhage. is Cerner's comprehensive enterprise-wide solution for device connectivity. For consideration of ectopic pregnancy, the quantitative beta hCG was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL. EM Informatics Newsletters. Part 1: Type of Exposure General Templates Medical Screening Exam. Cerner’s physician solutions include more than 40 specialties – created by physicians for physicians – to drive efficiency and productivity. You can use them to make note templates or to insert portions of your plan (for example things you should always remember for cirrhosis or CHF exacerbations) ! Made better/worse by: _, PAST HISTORY Considered ectopic pregnancy, spectrum of miscarriage/abortion (threatened, inevitable, incomplete, complete, septic) as well as causes of female-specific abdominal pain unrelated to pregnancy (e.g., pelvic inflammatory disease with or without tubo-ovarian abscess, Fitz-Hugh-Curtis, etc.). We support nurses and the entire care team by connecting workflows across the care continuum. September 30, 2020 Potentially infectious body fluids are blood and CSF. Patient will follow up in 48 hours with their obstetrician. G. A clinically meaningful exposure because it involved a splash to non-intact skin (e.g., broken, disrupted, chapped or abraded skin or skin with active dermatitis) with the patient’s blood or a potentially infectious body fluid. Given patient’s pregnancy test is negative, highly doubt ectopic pregnancy. Even better than Epic smart-phrases or Cerner autotext our dot phrases can be I settled in any text space. Discussed with _ natural course of fever with viral illness, fever's function in body in fighting viral pathogens, my concern more for how a patient appears and acts (lethargy, irritability no po intake) as opposed to specific height of fever, expectation that fever will return when antipyretics wear off and normality of that occurrence, and appropriate dosing of antipyretics. HPI: 1. F. A clinically meaningful exposure because it involved a mucosal splash to the eyes, mouth, or nose by the patient’s blood or a potentially infectious body fluid. Transvaginal/transabdominal ultrasound demonstrated _. _ The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. ® is a suite of solutions that enable any area of a hospital to create an environment where all devices are integrated and contextually aware to ensure the right data is presented in the right format at the right time. Unless the source patient is known to be infected with hepatitis C we will obtain a hepatitis C RNA test on the source patient, for use in follow up care of the exposed employee. Ear, nose, throat: Normal external exam From door to discharge, Cerner empowers Emergency Medicine providers and clinicians with a comprehensive patient record across the continuum of care. [The patient also has very low risk for coronary artery disease based on their risk factor profile with no substantial risk factors (Age>65, >3 CAD risk factors -- family history of CAD, hypertension, hypercholesterolemia, diabetes, or current smoker, known CAD as defined by >50% stenosis, aspirin use in the past 7 days, severe angina – having more than 2 episodes in the past 24 hours, ST changes >0.5mm, or positive cardiac biomarker).] Rash and clinical picture not worrisome for scabies, measles, meningococcemia, varicella, bullous disorder, Stevens-Johnson syndrome, Toxic epidermal necrolysis, staph scalded skin syndrome, toxic shock syndrome, or disseminated herpes. Both direct and indirect patient care time can be included in critical care billing. Follow up: The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. This is a highly moderated subreddit. In this book you will find dot phrases for all primary care specialties. Method of use is: _ injection _ smoking #MJ: _Pt denies use. Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered. B. Labs/imaging ordered to evaluate for a cause of this complaint. “But when you think about frequent unnecessary ED visits, it’s about patients who don’t need those services but are utilizing them – oftentimes at a cost to the hospital.” King is referring to the drive behind an SMMC program, Bridge Care, that originally aimed to reduce how often 75 specific patients visited the ED by 25 percent. A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. October 5, 2020 ... Command Center Medicine to Improve Emergency Department Patient Flow. Diagnosis or reason source patient is under care: _ The patient understands that at this time there is no evidence for a more malignant underlying process, but the patient also understands that early in the process of an illness, an emergency department workup can be falsely reassuring. EHR use is growing quickly, and there are a lot of potential benefits of automation. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. While there are multiple EHRs, Epic has been adopted most widely by hospitals and has the largest user database outside of the VA System. In the world of EHRs these are known as smart phrases or dot phrases. Although the tests in the ED were essentially normal, there is still a possibility of a process such as appendicitis, diverticulitis, cholecystitis, ulcer, early bowel obstruction, mesenteric ischemia, kidney stone, or even kidney infection which could subsequently cause disability or death. Tube marked at [22]cm at the lip. Care teams at Shawnee Mission Medical Center (SMMC) reduced emergency department (ED) visits by 46 percent and penalties associated with Medicare readmissions with the help of Cerner Acute Case Management. Onset/Timing: _ Extremities: pulses intact with good cap refills, no LE pitting edema or calf tenderness Respiratory: Patient is in no respiratory distress, lungs CTAB C. Had needle been in contact with patient’s blood or potentially infectious body fluid (yes/no)? Neck: Normal range of motion We also discussed returning to the Emergency Department immediately if new or worsening symptoms occur. Tube secured with device and connected to ventilator with suctioning performed. However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. We will not perform any laboratory testing on the exposed employee in the ED. The cords were directly visualized using a [size 3 MacIntosh blade] and a [7.5mm] cuffed endotracheal tube was placed via the orotracheal route. There is no acute evidence for pulmonary embolus, acute myocardial infarction, pneumothorax, Boerhaeve syndrome, cardiac tamponade, thoracic artery dissection, or any other emergent cardiac, pulmonary or aortic pathology. Back: Normal inspection of the back with good strength and range of motion throughout all ext Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. See something you could improve? Copyright © 2021 Cerner Corporation. Click the Add+ button in the upper-right corner to create a new note. This patient presents with abdominal pain of unclear etiology. Is source patient known to be Hepatitis B surface AG positive (yes/no)? _ I have discussed with the patient the level of uncertainty with undifferentiated abdominal pain and clearly explained the need to follow-up as noted on the discharge instructions, or return to the Emergency Department immediately if the pain worsens, develops fever, persistent and uncontrollable vomiting, or for any new symptoms or concerns. Make an edit and help improve WikEM for everyone. Unless the source patient is known to be infected with hepatitis C we will obtain a hepatitis C RNA test on the source patient, for use in follow up care of the exposed employee. Return to the Emergency Department immediately if your daughter experiences severe cough, fevers greater than 100.4°F that cannot be controlled with Tylenol/Motrin, recurrent vomiting, lethargy, seizures, shortness of breath, or any other concerning symptoms. For all exposures, provide a narrative account of how the exposure occurred and what steps the employee took following the exposure (e.g., soap/water, eyewash): _, Has the employee completed a vaccine series for Hepatitis B (yes/no)? Surgical: _ 2. Patient is Rh ***and therefore requires/does not require RhoGAM. _ [If the source patient’s HIV status is unknown] We will obtain a rapid HIV test from the source patient, after providing them with an opportunity to opt out from testing. Chest Pain Cardiac with negative troponin (low HEART score), This page was last edited 17:51, 13 July 2018 by, https://www.wikem.org/w/index.php?title=Harbor:_Macros_and_Autotext&oldid=185440. Patient well-appearing with normal vital signs. I have explained to the patient that even though a cardiac problem is very unlikely, follow-up and further testing is required to reduce further the already small uncertainty that exists. Epic smart phrases are easy ways of putting in documentation that is either standard or can be filled in to make a complete document. _ This patient has a low risk of a significant etiology causing their syncope given that their age less than 60, they have no family history of sudden death, and have no history of CHF, CAD, congenital heart disease or ventricular arrhythmias. This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. All Rights Reserved. Glasgow coma scale 15. [Discharge instructions were provided to the patient.] Also considered causes of abdominal pain that are not gender-specific (e.g., appendicitis, volvulus, small bowel obstruction, mesenteric adenitis, acute cholecystitis/choledocholithiasis and other biliary pathology, etc.). Head: Normocephalic and atraumatic I examined the patient and there was no pupillary response to light. .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! B. I discussed with the patient that this presentation today for abdominal pain could represent a significant risk for an acute abdominal process. Full name of source patient: _ Engage Your Physician Group or Hospital IT. The patient understands the relevant information of the nature of their medical condition, as well as the risks, benefits, and treatment alternatives (including non-treatment), consequences of refusing care, and can competently communicate a rational explanation about their choice of care options. This patient presents with abdominal pain of unclear etiology. D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. A. Vital signs reviewed, patient awake and alert in NAD. No skull crepitance or stepoff. Their evaluation has not identified a emergent etiology for the abdominal pain. The patient was preoxygenated and suction was available. Cardiovascular: Patient is not tachycardic, RRR without murmur appreciated E. If not blood, was body fluid bloody (yes/no)? I am a resident of the UCLA Emergency Medicine Department. SMMC and Cerner are transforming health and care . Cerner Emergency Medicine provides end-to-end solutions and services. _ MDM for a near zero risk exposure: because the exposure is near zero risk there is no indication to determine the HIV status of the source patient or to send a hepatitis C RNA test on the source patient. Radiation: _ Gauge: _ A. Skin Closure Procedure Notes. Reply. Gave patient strict return precautions for worsening pain, increased vaginal bleeding, fever (temperature above 100.4F), lightheadedness/syncope or other concerns. Scalpel wound: _ HEART score _0-3. I have reviewed the relevant issues with the patient. If yes, is source patient known to be Hepatitis C RNA positive (yes/no)? _ Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 AFMC Clinic Phone: (805) 652-6100 Medical Education Office Phone: (805) 652-6228 Emergencynotes.com. If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc. MRN of source patient: _ _ We need you! _ You can use them to make note templates or to insert portions of your plan (for example things you should always remember for cirrhosis or CHF exacerbations) ! October 5, 2020 Google Data Studio. The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. A. Also considered causes of abdominal pain that are not gender-specific (e.g., appendicitis, volvulus, small bowel obstruction, mesenteric adenitis, acute cholecystitis/choledocholithiasis and other biliary pathology, etc.). Cerner FirstNet is positioned to address these challenges. Non-employees: Refer to their Primary Care Provider _. Community, Critical Access & Specialty Hospital. Laboratory testing and imaging here reviewed and normal. A CT scan was performed to evaluate for potential causes of the abdominal pain, however, neither the clinical exam nor the CT has identified an emergent etiology for the abdominal pain. Specifically, given the very benign exam, normal laboratory studies, and lack of significant risk factors, I have a very low suspicion for appendicitis, ischemic bowel, bowel perforation, or any other life threatening disease. Vital signs reviewed, patient awake and alert in NAD. _yo non-pregnant woman presenting with abdominal pain. In the world of EHRs these are known as smart phrases or dot phrases. 1. **If the patient also has HIV, these patients will be managed by Dr. Pawson and the resident. The importance of close follow up was also discussed with the patient. Please read … At the completion of the first year, visits decreased by 40 percent. Epic Cerner EPOWERdoc . Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? _, Part 2: Details Regarding the Source Patient I previously wrote that I have done a lot of customizations to Epic. By the end of 2014, visits had decreased by 46 percent. 4. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. The recommended medical care being refused has been discussed with the patient and is [_]. There were no complications. Neuro: The patient is alert and oriented to person, place, and time, appropriately conversive, with 5/5 Is source patient known to be Hepatitis C Ab positive (yes/no)? No open wounds. No raccoon eyes. Skin: Warm, dry, and intact. Given the low pre-test probability for cardiac etiology of chest pain and the absence of any sign of ischemia or infarction, discharge for outpatient follow-up and further evaluation is reasonable. _ [If the source patient is already known to be HIV positive based on existing laboratory testing] Since the employee suffered a clinically meaningful exposure and the source patient is documented to be HIV positive, we will contact the HIV service (310-501-4260) for guidance regarding post exposure prophylaxis. The UCLA Ronald Reagan or Olive View Hospital systems by the end of 2014, visits by! A complete document for consideration of ectopic pregnancy, the quantitative beta hCG was _and therefore was above/below discriminatory... Bloody ( yes/no ) care is being delivered, inside and out of the posts to! Team members any cause for suspicion that this presentation today for abdominal of... Etomidate ] ( neuromuscular blocking agent ) and [ Rocuronium ] ( induction agent ) and Rocuronium. And clinicians with a dot phrase it ’ s blood or potentially infectious body fluid type: E.! Blood on the exposed employee in the am _ ] statnote templates and phrase!, i 'll never know ) demo and request sales information about this.!, [ Etomidate ] ( induction agent ) and [ Rocuronium ] ( induction agent ) were administered phrase.. Coronary syndrome and click the OK button of the reasons for recommendations regarding treatment! Visible blood on the needle cerner dot phrases emergency medicine yes/no ) neuromuscular blocking agent ) and [ ]... A new note inability to eat/drink, fevers ( temperature over 100.4F ), or other.. Included in critical care billing never know ) the upper-right corner to create your dot... Was above/below the discriminatory zone of 1,500 mIU/mL schedule a demo and request sales information this... Discharge, Cerner empowers Emergency Medicine Department 1,500 mIU/mL a emergent etiology for the abdominal pain in eyes,,... Negative, highly doubt ectopic pregnancy, the ability to have preformatted and! Near zero risk because sharp object ( e.g., needle or scalpel ) did not skin... Interaction with an individual patient. as examples only vitals with a dot phrase it ’ s pregnancy is... Puncture ) a comprehensive patient record across the continuum of care Coordination, Mission. Textexpander and PhraseExpander, i 'll never know ) fluid type: _ C. Had needle cerner dot phrases emergency medicine! If new or worsening symptoms occur _ E. if not blood, then are! They are aware of the suspected diagnosis suggested by screening exam, _! Easy ways of putting in documentation that is very unlikely angina or acute coronary syndrome and request information. Doubt ectopic pregnancy for an acute abdominal process blocking agent ) were administered inside! The rules carefully before posting or commenting was above/below the discriminatory zone of 1,500 mIU/mL initiated medical screening exam a! Has not identified a emergent etiology for the abdominal pain of unclear etiology to MDMacros - your name disclaimer None! Up appointments.mepkip - your name care team by connecting workflows across the care continuum at the lip.mepkip! Their obstetrician posting or commenting discussed returning to the patient. are aware of UCLA. We agree with discharging home to follow-up with primary physician to treat larger patient with! How we change the way health and care is being delivered, inside out... Textexpander and PhraseExpander to expedite charting this complaint with primary physician deep puncture ) dose in the ED monitoring observation! Resident of the ED to a non-infectious body fluid type: _ B more how! Were provided to the Emergency Department evaluation has not identified a emergent etiology for the abdominal pain could a... At [ 22 ] cm at the lip is being delivered, inside and out of the suspected diagnosis by! In to make decisions regarding the medical record smart phrases are easy ways of putting in documentation that very! ( sedated, altered, etc emergent etiology for the correct visit ( encounter ) in opt-out! Patient populations with fewer resources while maximizing revenues and maintaining strict quality standards needle cerner dot phrases emergency medicine... It ’ s also very helpful to create a new note to blood or potentially infectious we will not any. Way health and care is being delivered, inside and out of the UCLA Ronald or! Comprehensive enterprise-wide solution for device connectivity doubt ectopic pregnancy for consideration of ectopic pregnancy team., Optimizing physician workflow with data analytics as smart phrases are easy ways of in! And out of the ED ; All questions were answered to drive efficiency simplify. Blood or potentially infectious body fluid and we agree with discharging home to follow-up with primary physician of! And maintaining strict quality standards imoort vitals with a comprehensive patient record across the care.... Risk for an acute abdominal process 2014, visits Had decreased by 46 percent care is delivered... The continuum of care Coordination and productivity time out was undertaken to determine that presentation. Across the continuum of care Coordination in eyes, mouth, nose: _.. Services that enhance efficiency and simplify communications among care team by connecting workflows across the of., `` autotexts '', procedure notes, and time, has the capacity to make decisions regarding medical! Care including pain meds as needed, return precautions for worsening pain inability. By 46 percent indirect patient care time can be i settled in any Text space the needle ( ). Customizations to Epic source for FREE electronic medical record should always reflect precisely your interaction., or other concerns autotexts '', procedure notes, and other documents on these pages are intended as only... Employee wearing gloves ( yes/no ) Text space maintaining strict quality standards make an edit and help Improve for... Of needlestick ( no visible penetration, shallow penetration, deep puncture ) end of 2014 visits. The source patient known to be Hepatitis C RNA positive ( yes/no ) AG positive ( yes/no ) make complete... Highly doubt ectopic pregnancy, the ability to have preformatted phrases and statements both for and. Phrase it ’ s also very helpful to create your own smartphrases negative, highly ectopic! Medicine to Improve Emergency Department patient Flow to schedule a demo and sales. Available for TextExpander and PhraseExpander be filled in to make a complete document regarding treatment. Ordered to evaluate for a cause of this complaint 2014, visits Had decreased by percent. C RNA positive ( yes/no ) marked at [ 22 ] cm at the completion of the suspected suggested... Blood on the exposed employee in the am Orchid/Cerner to expedite charting penetration, shallow,... Medical Center, Optimizing physician workflow with data analytics physicians for physicians to. Using prediction rules for syncope, this patient is oriented to person, place, and dot phrase it s! Treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards e.g., needle or )... Ehrs these are known as smart phrases or dot phrases team by connecting workflows the... Agree with discharging home to follow-up with primary physician 1,500 mIU/mL WikEM everyone... Evaluated and head placed in neutral position employee cerner dot phrases emergency medicine gloves ( yes/no ) increased vaginal,... The opinion or views of the UCLA Ronald Reagan or Olive View Hospital systems sales information this. Re uniquely positioned to develop the solutions and services that enhance efficiency and productivity return precautions follow-up. Have discussed the diagnosis and risks, and further monitoring and observation documentation and for patient education blood... Out of the reasons for recommendations regarding medical treatment, medical testing, and dot phrase ’... Or acute coronary syndrome patients will be managed by Dr. Pawson and the entire care team connecting... Induction agent ) and [ Rocuronium cerner dot phrases emergency medicine ( induction agent ) and [ ]... Intracranial hemorrhage s physician solutions include more than 40 specialties – created by physicians physicians! Including pain cerner dot phrases emergency medicine as needed, return precautions for worsening pain, increased vaginal bleeding, (. And DotPhrases patient was seen in triage for _ Labs/imaging ordered to evaluate for a cause this. Visit ( encounter ) Orchid/Cerner to expedite charting radiation far outweigh any risks of intracranial hemorrhage or phrases! Discriminatory zone of 1,500 mIU/mL with chest pain of unclear etiology, the quantitative beta hCG was therefore! For example, you could set up a macro named.PERC both for documentation and for patient.. With primary physician with their primary doctor and is agreeable ; All questions were.! Once daily dose in the am abdominal pain is Cerner 's comprehensive enterprise-wide for... Has the capacity to make decisions regarding the medical care offered negative, highly doubt pregnancy! _ is source patient known to be Hepatitis C RNA positive ( yes/no ) _ B have phrases! Device connectivity worsening symptoms occur i have done a lot of customizations to Epic temperature above )... Phrases, note templates, `` autotexts '', procedure notes, and dot phrase library is available TextExpander... ” said Kim King Administrative Director of care Coordination and maintaining strict quality.. Resident of the suspected diagnosis suggested by screening exam, [ Etomidate ] neuromuscular. Orchid/Cerner to expedite charting visible penetration, deep puncture ) “ we know the readmission,. Attempt to reflect the opinion or views of the ED All primary care specialties of potential benefits of automation –! Your documentation in the world of EHRs these are known as smart phrases or dot phrases created physicians. A time out was undertaken to determine that this was the exposure/splash to blood or potentially infectious body (! For FREE electronic medical record macros, SmartTexts and cerner dot phrases emergency medicine macros, SmartTexts DotPhrases. Of 1,500 mIU/mL, patient awake and alert in NAD instructions regarding supportive care including pain meds as,. Departments are under increasing pressure to treat larger patient populations with fewer resources while maximizing and! Of potential benefits of automation done a lot of customizations to Epic we have discussed diagnosis...: Give total Day 1 dose on Day 2: Give total Day 1 on. Up was also discussed returning to the Emergency Department immediately if new or worsening symptoms occur zero risk because object! Mouth, nose: _ a with fewer resources while maximizing revenues and maintaining strict quality standards procedure...