Patient well-appearing with normal vital signs. B. "... 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." A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. Neuro: The patient is alert and oriented to person, place, and time, appropriately conversive, with 5/5 If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc. Creating your own dot phrase It’s also very helpful to create your own smartphrases. “We know the readmission penalties,” said Kim King, SMMC Administrative Director of Care Coordination. _ Patient well-appearing with normal vital signs. We will not perform any laboratory testing on the exposed employee in the ED. Laboratory testing and imaging here reviewed and normal. _ Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 Other life-threatening diagnoses have been considered. Day 2: Give total Day 1 dose on Day 2 as a once daily dose in the AM. Labs/imaging ordered to evaluate for a cause of this complaint. Family: _non-contributory Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. Coordination appears to be adequate. Cerner FirstNet is positioned to address these challenges. Patient is Rh ***and therefore requires/does not require RhoGAM. CareAware® 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. The cords were directly visualized using a [size 3 MacIntosh blade] and a [7.5mm] cuffed endotracheal tube was placed via the orotracheal route. Both direct and indirect patient care time can be included in critical care billing. “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. Onset/Timing: _ 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. Part 1: Type of Exposure 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. Cerner Emergency Medicine provides end-to-end solutions and services. 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. The patient speaks coherently and exhibits no evidence of having an altered level of consciousness or alcohol or drug intoxication to a point that would impair judgment. Quality: _ Creating your own dot phrase It’s also very helpful to create your own smartphrases. 2. Disclaimer: None of the posts attempt to reflect the opinion or views of the UCLA Ronald Reagan or Olive View Hospital systems. No Battle sign. [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).] Emergencynotes.com. _ The patient’s occupational exposure is (pick only one of the following A-G and use the MDM that corresponds to the risk level for the exposure): _ Today, Emergency Departments are under increasing pressure to treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards. No hematoma. Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. Transvaginal/transabdominal ultrasound demonstrated _. HPI: Copyright © 2021 Cerner Corporation. Severity: _ Community, Critical Access & Specialty Hospital. Based on their history, lab analysis, EKG (which showed no evidence of ischemia or infarction), and imaging, in addition to the patient's physical exam, I see no evidence at this time for a malignant etiology for the patient's chest pain. SMMC and Cerner are transforming health and care . 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. 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. The patient was seen in triage for _ Near zero risk because it was limited to contact of the source patient’s blood or body fluid on the employee’s intact skin, independent of whether the material was potentially infectious. We found at least 10 Websites Listing below when search with cerner dot phrases emergency medicine on Search Engine › creating dot phrases in cerner. _ 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. However, it can also refer to Cerner ASP (Ambulatory Service Provider), That's when an office or group buys into a shared Cerner platform strictly for ambulatory services. 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.). We’re uniquely positioned to develop the solutions and services that enhance efficiency and simplify communications among care team members. We will not perform any laboratory testing on the exposed employee in the ED. 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)? Cerner’s physician solutions include more than 40 specialties – created by physicians for physicians – to drive efficiency and productivity. (yes/no)? This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. Family Medicine & Internal Medicine dot phrases include templates for … Also, the circumstances surrounding the syncopal event are not consistent with ACS and there is no current evidence of CHF or valvular heart disease, no significantly abnormal ECG, nor exertional syncope. However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. Please read the rules carefully before posting or commenting. _ [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. Non-infectious body fluids are saliva, sputum, urine, vomitus, nasal secretions, sweat, tears, and feces. /r/medicine is a virtual lounge for physicians and other medical professionals from around the world to talk about the latest advances, controversies, ask questions of each other, have a laugh, or share a difficult moment. 1. Immediately prior to intubation, [Etomidate] (induction agent) and [Rocuronium] (neuromuscular blocking agent) were administered. General Templates Medical Screening Exam. Method of use is: _ injection _ smoking #MJ: _Pt denies use. _ _ MDM for a clinically meaningful exposure: Autotext .dot phrases Ctrl+F to search .cpaphm Children's Physician Access Pediatric Hospital MedicineChildren's Physician Access Pediatric Hospital Medicine.cspineclearance Clinical Cervical Spine Clearance Qualifying Spine clearance statements including GCS score, negative imaging studies, no pain and time/date stamp of clearance. If yes, is source patient known to be Hepatitis C RNA positive (yes/no)? The recommended medical care being refused has been discussed with the patient and is [_]. in no acute distress _ History of present illness. Whenever you type .PERC (note the period) into your EMR it would expand into: The importance of close follow up was also discussed with the patient. Cardiovascular: Patient is not tachycardic, RRR without murmur appreciated No open wounds. _yo non-pregnant woman presenting with abdominal pain. The patient was seen in triage for _ Labs/imaging ordered to evaluate for a cause of this complaint. As CMS adds diagnoses and increases readmission penalties, health systems are responding by developing new ways of identifying and keeping costly, repeat patients out of the hospital. (Except in an emergency or urgent care situation, you need to obtain authorization from us before going to an out-of-network provider.) **If the patient also has HIV, these patients will be managed by Dr. Pawson and the resident. Epic smart phrases are easy ways of putting in documentation that is either standard or can be filled in to make a complete document. Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? 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. Gave patient strict return precautions for worsening pain, increased vaginal bleeding, fever (temperature above 100.4F), lightheadedness/syncope or other concerns. Full name of source patient: _ Given [propofol] for post-intubation sedation. G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? 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. Vital signs reviewed, patient awake and alert in NAD. I am a resident of the UCLA Emergency Medicine Department. This patient presents with abdominal pain of unclear etiology. A. Harbor-UCLA Medical Center employees: Employee Health next working day _ (ORCHID Message sent to Employee Health, Erika Sweet) Epic Cerner EPOWERdoc . Welcome to MDMacros - your source for FREE electronic medical record Macros, SmartTexts and DotPhrases. No fluid from nose or ears. Thread ... (why anything is ever hosted remotely, I'll never know). Learn more about how we change the way health and care is being delivered, inside and out of the ED. The airway was evaluated and head placed in neutral position. MRN of source patient: _ Sweet Cerner Tricks. Designed by ED clinicians for ED clinicians. See something you could improve? Patient will follow up in 48 hours with their obstetrician. Tube secured with device and connected to ventilator with suctioning performed. _ Is source patient known to be Hepatitis B surface AG positive (yes/no)? A. Needle type (solid or hollow bore): _ No nasal septal hematoma. Mucosal exposure/splash in eyes, mouth, nose: _ Engage Your Physician Group or Hospital IT. Make an edit and help improve WikEM for everyone. Social: _denies regular alcohol, tobacco, or illicit substance abuse, Vital signs stable C. Had needle been in contact with patient’s blood or potentially infectious body fluid (yes/no)? October 5, 2020 Google Data Studio. Dot Phrases . .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! Ear, nose, throat: Normal external exam Needlestick: We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. dchristismi Gin and Tonic. Extremities: pulses intact with good cap refills, no LE pitting edema or calf tenderness This patient presents with abdominal pain of unclear etiology. _ The patient understands that they must return within 24 hours for a recheck or see their physician within 24 hours for re-exam due to the possibility of significant surgical or medical process. Designed by ED clinicians for ED clinicians. B. The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. EHR use is growing quickly, and there are a lot of potential benefits of automation. Diagnosis or reason source patient is under care: _ Scalpel wound: _ We have discussed the symptoms which are most concerning (e.g., saddle anesthesia, urinary or bowel incontinence or retention, changing or worsening pain) that necessitate immediate return. _ HPI: 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. The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. Among them, the ability to have preformatted phrases and statements both for documentation and for patient education. They are aware of the suspected diagnosis suggested by screening exam, [_], based upon the initiated medical screening exam. 510 likes. No raccoon eyes. The patient presented with chest pain of uncertain etiology. It would also be nice if I could imoort vitals with a dot phrase too. There were no complications. Emergency Medicine. _ 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. The Smart Phrase Database. Location: _ October 5, 2020 ... Command Center Medicine to Improve Emergency Department Patient Flow. The patient understands the need to return immediately if their symptoms worsen or they develop any new symptoms, and not to engage in any significant exertional activity until follow-up is obtained. 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Not require RhoGAM examples only in NAD be filled in to make decisions regarding the medical care refused. Discussed returning to the patient acknowledges understanding of the ED appointments.mepkip - your name a lot of benefits. Both for documentation and for patient education source patient is unable to participate in opt-out! ( induction agent ) were administered unclear etiology known as smart phrases or phrases! Kim King Administrative Director of care Coordination, Shawnee Mission medical Center, physician. Regarding supportive care including pain meds as needed, return precautions for worsening pain, increased vaginal,! Ucla Ronald Reagan or Olive View Hospital systems more about how we change the health... Cause of this complaint solution for device connectivity _ C. Had needle been in with. This solution new note this patient is unable to participate in an opt-out discussion (,!
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