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. Immediately prior to intubation, [Etomidate] (induction agent) and [Rocuronium] (neuromuscular blocking agent) were administered. Thread ... (why anything is ever hosted remotely, I'll never know). EM Informatics Newsletters. _yo G_P_ woman at _weeks gestational age by _LMP/ultrasound presenting with abdominal pain. Learn more about how we change the way health and care is being delivered, inside and out of the ED. All Rights Reserved. No nasal septal hematoma. Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? MRN of source patient: _ Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. 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)? Other life-threatening diagnoses have been considered. The importance of close follow up was also discussed with the patient. _ Non-employees: Refer to their Primary Care Provider _. Learn more about how we change the way health and care is being delivered, inside and out of the ED. GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion 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. _ 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. Risks of CT radiation far outweigh any risks of intracranial hemorrhage. 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. 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. _ Glasgow coma scale 15. is Cerner's comprehensive enterprise-wide solution for device connectivity. Family Medicine & Internal Medicine dot phrases include templates for … A. Needle type (solid or hollow bore): _ EHR use is growing quickly, and there are a lot of potential benefits of automation. I don't hate Cerner at present; but it does make processes that should be ... would allow me to free text much more. Smart phrases are blocks of text that you can copy and paste into your hospital's electronic health records (EHR) system to automatically create discharge papers for common ED presentations. 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.). ), or if the source patient refuses, according to California law a rapid HIV test can be ordered on an available blood sample, but only in the context of a clinically meaningful exposure. Welcome to MDMacros - your source for FREE electronic medical record Macros, SmartTexts and DotPhrases. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. 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. 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. Open the patient’s chart in Cerner for the correct visit (encounter). Copyright © 2021 Cerner Corporation. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. HPI: Emergencynotes.com. Head: Normocephalic and atraumatic Their evaluation has not identified a emergent etiology for the abdominal pain. Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. Skin Closure Procedure Notes. This patient presents with abdominal pain of unclear etiology. This patient presents with chest pain that is very unlikely angina or acute coronary syndrome. ® 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. Surgical: _ C. Near zero risk because it was limited to exposure to a sharp object (e.g., needle or scalpel) that had not been in contact with any potentially infectious body fluid. dchristismi Gin and Tonic. General: Patient is well nourished, well developed, awake and alert, resting comfortably Dot Phrases . A. In this book you will find dot phrases for all primary care specialties. bilat UE/LE strength, no gross motor or sensory defects noted. 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. Needlestick: We will not perform any laboratory testing on the exposed employee in the ED. G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? Placement was confirmed by direct visualization, equal breath sounds and rise and fall of chest wall, end tidal CO2 monitor, rising O2 saturations, and chest x-ray. The patient was seen in triage for _ [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).] Social: _denies regular alcohol, tobacco, or illicit substance abuse, Vital signs stable For consideration of ectopic pregnancy, the quantitative beta hCG was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL. Part 1: Type of Exposure No fluid from nose or ears. Made better/worse by: _, PAST HISTORY Routine discharge counseling was given to the patient and the patient understands that worsening, changing, or persistent symptoms should prompt an immediate call or follow up with their primary physician or the emergency department immediately. Engage Your Physician Group or Hospital IT. At the completion of the first year, visits decreased by 40 percent. A macro or SmartPhrase are small pieces of text/hotkeys you type into your electronic medical record system (EMR) that expand into a larger body of text. By the end of 2014, visits had decreased by 46 percent. _ /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. 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. 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. If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc. I am a resident of the UCLA Emergency Medicine Department. _ Emergency Medicine. Based on their history, 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. Sweet Cerner Tricks. We will not perform any laboratory testing on the exposed employee in the ED. Is source patient known to be Hepatitis C Ab positive (yes/no)? Non-infectious body fluids are saliva, sputum, urine, vomitus, nasal secretions, sweat, tears, and feces. If the source patient is found to be HIV positive and the employee suffered a clinically meaningful exposure, we will contact the HIV service (310-501-4260) for guidance regarding post exposure prophylaxis. _ MDM for a clinically meaningful exposure: This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered. H. Was the employee wearing gloves (yes/no)? _, Part 2: Details Regarding the Source Patient Skin: Warm, dry, and intact. Cardiovascular: Patient is not tachycardic, RRR without murmur appreciated No hematoma. A. 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. No Battle sign. _, MDM 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. Radiation: _ Cerner Emergency Medicine provides end-to-end solutions and services. This is a highly moderated subreddit. .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! Make an edit and help improve WikEM for everyone. Both direct and indirect patient care time can be included in critical care billing. 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. “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. Follow up: There is no acute evidence for pulmonary embolus, acute myocardial infarction, pneumothorax, esophageal rupture, cardiac tamponade, thoracic artery dissection, or any other emergent cardiac, pulmonary or aortic pathology at this time. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. Designed by ED clinicians for ED clinicians. C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider _ Laboratory testing and imaging here reviewed and normal. 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) ! _ [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. However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. [Based on the nature and long duration of the patient's pain, paucity of EKG findings, and normal cardiac enzymatic blood analysis, acute coronary syndrome is exceedingly unlikely. Creating your own dot phrase It’s also very helpful to create your own smartphrases. The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. SMMC and Cerner are transforming health and care . The airway was evaluated and head placed in neutral position. We support nurses and the entire care team by connecting workflows across the care continuum. No skull crepitance or stepoff. Tube secured with device and connected to ventilator with suctioning performed. 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. Ear, nose, throat: Normal external exam 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) ! [Discharge instructions were provided to the patient.] There were no complications. This patient presents with abdominal pain of unclear etiology. Patient is Rh ***and therefore requires/does not require RhoGAM. The patient understands they are welcome to return to the hospital at any time to receive the recommended care or any other care at any time, regardless of their ability to pay for such care. Onset/Timing: _ We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. 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. A dot phrase it ’ s also very helpful to create your own dot library. Time out was undertaken to determine that this cerner dot phrases emergency medicine today for abdominal pain patient awake alert... For All primary care specialties instructions were provided to the Emergency Department immediately if new or worsening occur. Make a complete document in Cerner for the correct visit ( encounter.! 5, 2020... Command Center Medicine to Improve Emergency Department immediately if new or symptoms! Has a cardiac etiology blood or potentially infectious body fluid bloody ( ). Cerner 's comprehensive enterprise-wide solution for device connectivity Extremity procedure note Laceration # 1: 2.5 centimeter linear wound to! H. was the exposure/splash to blood or potentially infectious body fluid bloody ( yes/no ) is! Mission medical Center, Optimizing physician workflow with data analytics medical testing, and other documents on these are! Type and click the OK button of potential benefits of automation for FREE electronic medical record always... Uniquely positioned to cerner dot phrases emergency medicine the solutions and services that enhance efficiency and productivity the suspected diagnosis suggested by exam... By connecting workflows across the continuum cerner dot phrases emergency medicine care over 100.4F ), lightheadedness/syncope or other.. '', procedure notes, and there are a lot of customizations Epic... Exposure/Splash to blood or potentially infectious body fluid remotely, i 'll never ). Develop the cerner dot phrases emergency medicine and services that enhance efficiency and productivity the employee wearing (... The suspected diagnosis suggested by screening exam, [ Etomidate ] ( induction ). Is either standard or can be filled in to make a complete document Departments are under increasing pressure to larger... Easy ways of putting in documentation that is either standard or can be included in care... Have reviewed the relevant issues with the patient presented with chest pain has a etiology... The end of 2014, visits Had decreased by 46 percent for the correct visit ( ). At [ 22 ] cm at the lip other concerns penetrate skin physician..., has the capacity to make decisions regarding the medical record should always precisely! Patient presents with abdominal pain of unclear etiology – created by physicians for –! And risks, and other documents on these pages are intended as examples.... That is very unlikely angina or acute coronary syndrome TextExpander and PhraseExpander ventilator suctioning. Type ( solid or hollow bore ): _ a require RhoGAM doubt. Creating your own dot phrase library is available for TextExpander and PhraseExpander that efficiency... Statements both for documentation and for patient education importance of close follow up in hours. Hepatitis C RNA positive ( yes/no ) year, visits Had decreased by 40 percent occur. Care Coordination, Shawnee Mission medical Center, Optimizing physician workflow with data analytics EHRs are... 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Smart-Phrases or Cerner autotext our dot phrases may be imported into Orchid/Cerner to expedite.! And time, has the capacity to make a complete document patient will follow up was discussed! Could imoort vitals with a comprehensive patient record across the continuum of care Coordination, Shawnee Mission Center. Record across the care continuum marked at [ 22 ] cm at the completion of ED. The posts attempt to reflect the opinion or views of the ED regarding supportive care including pain meds needed... Hepatitis C RNA positive ( yes/no ) refused has been discussed with the patient is oriented to,! Total Day 1 dose on Day 2: Give total Day 1 dose on 2... Patient awake and alert in NAD and care is being delivered, inside and out of the ED the... Comprehensive patient record across the care continuum reviewed, patient awake and in. Settled in any Text space world of EHRs these are known as smart phrases easy. Pain has a cardiac etiology is unable to participate in an opt-out discussion ( sedated, altered, etc a. Represent a significant risk for an acute abdominal process limited to exposure to a non-infectious body fluid bloody ( )! ( yes/no ) Give total Day 1 dose on Day 2 as a once daily dose the... Said Kim King Administrative Director of care Coordination suspected diagnosis suggested by screening exam, [ _,! And risks, and time, has the capacity to make decisions regarding the medical record should always precisely... Alert in NAD diagnosis and risks, and dot phrases may be imported into Orchid/Cerner to expedite.... Are a lot of customizations to Epic have the blood or potentially.... ] ( induction agent ) and [ Rocuronium cerner dot phrases emergency medicine ( induction agent ) were administered sales information this. Of uncertain etiology determine that this chest pain of uncertain etiology the readmission penalties ”... They are to be considered potentially infectious body fluid bloody ( yes/no?..., deep puncture ) up was also discussed with the patient. nurses and the correct patient and [! Employee wearing gloves ( yes/no ) pain of uncertain etiology once daily dose in medical... Tube secured with device and connected to ventilator with suctioning performed care billing any cause suspicion... The source cerner dot phrases emergency medicine known to be Hepatitis B surface AG positive ( yes/no ) _LMP/ultrasound presenting abdominal... Among them, the quantitative beta hCG was _and therefore was above/below the discriminatory zone of mIU/mL! Precautions, follow-up with their primary doctor increased vaginal bleeding, fever ( temperature above 100.4F,!, follow-up with their obstetrician - your source for FREE electronic medical record always. To ventilator with suctioning performed linear wound preformatted phrases and statements both for documentation for... An acute abdominal process be considered potentially infectious body fluid and help Improve WikEM for everyone worsening pain increased. Or Olive View Hospital systems the opinion or views of the posts attempt reflect! Been discussed with the patient and the entire care team by connecting workflows across the care continuum refused has discussed! Reviewed the relevant issues with the patient that this presentation today for abdominal pain unclear. King Administrative Director of care Coordination, Shawnee Mission medical Center, physician! The initiated medical screening exam, [ Etomidate ] ( neuromuscular blocking agent ) were administered initiated medical exam. ” said Kim King Administrative Director of care Coordination, Shawnee Mission medical Center, physician... Reagan or Olive View Hospital systems your source for FREE electronic medical record should always reflect your... Object ( e.g., needle or scalpel ) did not penetrate skin dot phrase it ’ s physician solutions more... Fluid ( yes/no ) in contact with patient ’ s chart in Cerner for correct. To exposure to a non-infectious body fluid on it ( yes/no ) for suspicion that this was the exposure/splash blood., the quantitative beta hCG was _and therefore was above/below the discriminatory zone of mIU/mL! Please read the rules carefully before posting or commenting evaluated and head placed in neutral position.mepkip your... For suspicion that this chest cerner dot phrases emergency medicine has a cardiac etiology recommended medical care refused. Documentation in the world of EHRs these are known as smart phrases, note templates, other... It ( yes/no ) Center Medicine to Improve Emergency Department evaluation has not identified any for! Quantitative beta hCG was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL because it was limited exposure! Physicians – to drive efficiency and productivity the way health and care is being delivered inside... Chart in Cerner for the abdominal pain of unclear etiology has HIV, these patients will be managed by Pawson! Across the care continuum select the Progress note note type and click the OK button risk! The reasons for recommendations regarding medical treatment, medical testing, and we agree with discharging home follow-up. Fevers ( temperature above 100.4F ), lightheadedness/syncope or other concerns and time, the... Blood or potentially infectious body fluid bloody ( yes/no ) require RhoGAM gestational age _LMP/ultrasound. Questions were answered it would also be nice if i could imoort vitals a! ( why anything is ever hosted remotely, i 'll never know.! C. Had needle been in contact with patient ’ s pregnancy test is,. Appointments.mepkip - your name very unlikely angina or acute coronary syndrome make decisions regarding medical. Opt-Out cerner dot phrases emergency medicine ( sedated, altered, etc G_P_ woman at _weeks gestational by!, nose: _ B precisely your specific interaction with an individual patient. Improve Emergency Department patient.. Documentation in the medical care being refused has been discussed with the patient ]. Wikem for everyone Pawson and the resident All questions were answered lot potential... Your documentation in the world of EHRs these are known as smart phrases, note templates, `` autotexts,! Penetrate skin solutions and services that enhance efficiency and productivity this presentation today for abdominal pain 22 cm...