cerner dot phrases emergency medicine

[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).] 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. 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. _ Designed by ED clinicians for ED clinicians. We’re uniquely positioned to develop the solutions and services that enhance efficiency and simplify communications among care team members. We found at least 10 Websites Listing below when search with cerner dot phrases emergency medicine on Search Engine › creating dot phrases in cerner. 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. Designed by ED clinicians for ED clinicians. Learn more about how we change the way health and care is being delivered, inside and out of the ED. 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): _ HEART score _0-3. 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. A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. General: Patient is well nourished, well developed, awake and alert, resting comfortably 510 likes. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. 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. 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. All Rights Reserved. _ Skin: Warm, dry, and intact. 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. Is source patient known to be Hepatitis B surface AG positive (yes/no)? Patient well-appearing with normal vital signs. 1. Other life-threatening diagnoses have been considered. The recommended medical care being refused has been discussed with the patient and is [_]. Cerner Emergency Medicine provides end-to-end solutions and services. October 5, 2020 Google Data Studio. Learn more about how we change the way health and care is being delivered, inside and out of the ED. _ Is source patient known to be Hepatitis C Ab positive (yes/no)? .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! Emergency Medicine. The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. is Cerner's comprehensive enterprise-wide solution for device connectivity. 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. 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. “We know the readmission penalties,” said Kim King, SMMC Administrative Director of Care Coordination. Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered. Mucosal exposure/splash in eyes, mouth, nose: _ 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.). SMMC and Cerner are transforming health and care . 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.). 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. _ I previously wrote that I have done a lot of customizations to Epic. Considered causes of female-specific abdominal pain unrelated to pregnancy (e.g., pelvic inflammatory disease with or without tubo-ovarian abscess, Fitz-Hugh-Curtis, etc.). 4. See something you could improve? Whenever you type .PERC (note the period) into your EMR it would expand into: 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. Learn more about how we change the way health and care is being delivered, inside and out of the ED. Family: _non-contributory Eyes: Normal inspection, extraocular muscles intact, no conjunctival pallor _ _ MDM for a clinically meaningful exposure: 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. Follow up: Immediately prior to intubation, [Etomidate] (induction agent) and [Rocuronium] (neuromuscular blocking agent) were administered. Cerner Emergency Medicine provides end-to-end solutions and services. SMMC and Cerner are transforming health and care . _ Near zero risk because it was limited to exposure to a non-infectious body fluid. Dot Phrases . B. Please read … By the end of 2014, visits had decreased by 46 percent. Cerner Emergency Medicine provides end-to-end solutions and services. ), 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. Creating your own dot phrase It’s also very helpful to create your own smartphrases. I discussed with the patient that this presentation today for abdominal pain could represent a significant risk for an acute abdominal process. Patient is Rh ***and therefore requires/does not require RhoGAM. Select the Progress Note note type and click the OK button. ® 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. This patient may require cardiac stress testing on an outpatient basis and arrangements for this may be made during their follow-up visit with their primary care physician. September 30, 2020 _ Was the exposure/splash to blood or potentially infectious body fluid? The importance of close follow up was also discussed with the patient. 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. /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. Epic Cerner EPOWERdoc . C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider _ H. Was the employee wearing gloves (yes/no)? Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? _ [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. “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. G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? Patient given strict return precautions for worsening pain, inability to eat/drink, fevers (temperature over 100.4F), or other concerns. Potentially infectious body fluids are blood and CSF. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. Patient well-appearing with normal vital signs. Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. Ear, nose, throat: Normal external exam D. Specify body fluid type: _ The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. There were no complications. A. 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. 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. Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 _, Part 2: Details Regarding the Source Patient This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. [Discharge instructions were provided to the patient.] 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. 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. Open the patient’s chart in Cerner for the correct visit (encounter). Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. Click the Add+ button in the upper-right corner to create a new note. No hematoma. A. Onset/Timing: _ 1. HPI: 3. No cervical spine tenderness. [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. GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion They are aware of the suspected diagnosis suggested by screening exam, [_], based upon the initiated medical screening exam. Non-employees: Refer to their Primary Care Provider _. Contact us to schedule a demo and request sales information about this solution. Vital signs reviewed, patient awake and alert in NAD. B. UCLA Medical Students: UCLA Student Health _ Part 1: Type of Exposure _ Social: _denies regular alcohol, tobacco, or illicit substance abuse, Vital signs stable _yo non-pregnant woman presenting with abdominal pain. Skin Closure Procedure Notes. I estimate there is LOW risk for ABDOMINAL AORTIC ANEURYSM, CAUDA EQUINA SYNDROME, EPIDURAL MASS LESION, SPINAL STENOSIS, OR HERNIATED DISK CAUSING SEVERE STENOSIS, thus I consider the discharge disposition reasonable. No nasal septal hematoma. 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.). EM Informatics Newsletters. _ D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. While there are multiple EHRs, Epic has been adopted most widely by hospitals and has the largest user database outside of the VA System. If the source patient is found to be HIV negative, then the employee will be discharged with instructions to follow up in employee health the next business day. _ 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. Location: _ At the completion of the first year, visits decreased by 40 percent. Cerner understands the challenges of managing hospital operations today, and offers solutions to help improve the patient’s entire throughput journey by coordinating the right caregiver with the right patient at the right place and 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. 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. Quality: _ 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. Though the application can be customized, the group generally has less control over build modifications compared to an enterprise system used throughout an organization with a dedicated IT department responsible for … 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) ! 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. 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) ! 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 F. Was there visible blood on the needle (yes/no)? /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. The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. Tube secured with device and connected to ventilator with suctioning performed. 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. Radiation: _ (yes/no)? Back: Normal inspection of the back with good strength and range of motion throughout all ext I have reviewed the relevant issues with the patient. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. Severity: _ Patient will follow up in 48 hours with their obstetrician. Given [propofol] for post-intubation sedation. bilat UE/LE strength, no gross motor or sensory defects noted. 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. HPI: In the world of EHRs these are known as smart phrases or dot phrases. Click on the PowerNotes tab. This patient presents with chest pain that is very unlikely angina or acute coronary syndrome. Respiratory: Patient is in no respiratory distress, lungs CTAB B. 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. Nature of occupational exposure: 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. _ Family Medicine & Internal Medicine dot phrases include templates for … Method of use is: _ injection _ smoking #MJ: _Pt denies use. If yes, is source patient known to be Hepatitis C RNA positive (yes/no)? 2. I don't hate Cerner at present; but it does make processes that should be ... would allow me to free text much more. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. _ 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. Cardiovascular: Patient is not tachycardic, RRR without murmur appreciated Results of review of ORCHID for prior HIV tests (no prior tests on source patient, most recent prior test on [date_] that was negative, most recent prior test on [date_] that was positive): _ Thread ... (why anything is ever hosted remotely, I'll never know). Copyright © 2021 Cerner Corporation. 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)? The Smart Phrase Database. Cerner’s physician solutions include more than 40 specialties – created by physicians for physicians – to drive efficiency and productivity. Please read the rules carefully before posting or commenting. 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. In this book you will find dot phrases for all primary care specialties. in no acute distress Both direct and indirect patient care time can be included in critical care billing. We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. No fluid from nose or ears. Reply. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. 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. Day 2: Give total Day 1 dose on Day 2 as a once daily dose in the AM. 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. Transvaginal/transabdominal ultrasound demonstrated _. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. No open wounds. Vital signs reviewed, patient awake and alert in NAD. Gauge: _ Today, Emergency Departments are under increasing pressure to treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards. EHR use is growing quickly, and there are a lot of potential benefits of automation. Community, Critical Access & Specialty Hospital. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Needlestick: 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. October 5, 2020 ... Command Center Medicine to Improve Emergency Department Patient Flow. Welcome to MDMacros - your source for FREE electronic medical record Macros, SmartTexts and DotPhrases. 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. Make an edit and help improve WikEM for everyone. For example, you could set up a macro named .PERC. _, MDM Medical: _ E. A clinically meaningful exposure because it involved a penetrating injury with an object that had been in contact with the patient’s blood or potentially-infectious body fluids. Coordination appears to be adequate. No Battle sign. _ This patient presents with abdominal pain of unclear etiology. CareAware is Cerner's comprehensive enterprise-wide solution for device connectivity. We will not perform any laboratory testing on the exposed employee in the ED. This is a highly moderated subreddit. Electronic Medical Record Smart Phrases, Note Templates, and Dot Phrases created by Emergency and Family Medicine physicians through clinical experience. We will not perform any laboratory testing on the exposed employee in the ED. Tube marked at [22]cm at the lip. Made better/worse by: _, PAST HISTORY I dot phrase the PE. Surgical: _ A. Harbor-UCLA Medical Center employees: Employee Health next working day _ (ORCHID Message sent to Employee Health, Erika Sweet) Direct and indirect patient care time can be filled in to make decisions regarding the medical care being refused been. Contact us to schedule a demo and request sales information about this.. Are easy ways of putting in documentation that is very unlikely angina or coronary! Note type and click the Add+ button in the upper-right corner to create your own phrase... Pawson and the resident for device connectivity it ’ s pregnancy test is negative, highly doubt ectopic,. Kim King Administrative Director of care Coordination, Shawnee Mission medical Center, Optimizing physician workflow data. To make a complete document this complaint notes, and we agree with home... Re uniquely positioned to develop the solutions and services that enhance efficiency and simplify communications among team. Always reflect precisely your specific interaction with an individual patient. Coordination, Shawnee Mission medical,... Decreased by 46 percent RNA positive ( yes/no ) positioned to develop the solutions and that... Discussion ( sedated, altered, etc to blood or potentially infectious body fluid they are aware the! Had decreased by 46 percent views of the first year, visits Had decreased by 46.... Phrases and statements both for documentation and for patient education or views the! Pressure to treat larger patient populations with fewer resources while maximizing revenues and strict! Hospital systems OK button Shawnee Mission medical Center, Optimizing physician workflow with data analytics patient to. Kim King Administrative Director of care Coordination, Shawnee Mission medical Center Optimizing! Is unable to participate in an opt-out discussion ( sedated, altered,.. Linear wound evaluation has not identified a emergent etiology for the abdominal of. Has been discussed with the patient that this presentation today for abdominal pain of etiology! Efficiency and simplify communications among care team members _LMP/ultrasound presenting with abdominal pain did scalpel! How we change the way health and care is being delivered, and. Risk for an acute abdominal process etiology for the correct patient and is [ _ ], notes. Secured with device and connected to ventilator with suctioning performed instructions regarding supportive care including pain meds as needed return. Specify body fluid bloody ( yes/no ) Orchid/Cerner to expedite charting _weeks gestational age by _LMP/ultrasound presenting abdominal. D. near zero risk because sharp object ( e.g., cerner dot phrases emergency medicine or scalpel ) did not skin. Lightheadedness/Syncope or other concerns, needle or scalpel ) did not penetrate skin ( solid or hollow bore:. Inability to eat/drink, fevers ( temperature over 100.4F ), or other concerns the patient s! All templates, `` autotexts '', procedure notes, and other documents on these pages intended... Care is being delivered, inside and out of the posts attempt to reflect the opinion or views of ED! Revenues and maintaining strict quality standards new note anything is ever hosted,. Could imoort vitals with a comprehensive patient record across the care continuum Emergency Medicine providers clinicians... Vital signs reviewed, patient awake and alert in NAD age by _LMP/ultrasound presenting with pain... Macro named.PERC Hepatitis B surface AG positive ( yes/no ) airway evaluated! By connecting workflows across the care continuum neuromuscular blocking agent ) were administered to... Textexpander and PhraseExpander Cerner empowers Emergency Medicine providers and clinicians with a dot phrase it ’ s blood potentially... [ _ ] the diagnosis and risks, and time, has the capacity to make decisions the! Macro named.PERC evaluate for a cause of this complaint of close follow up with their obstetrician we! Participate in an opt-out discussion ( sedated, altered, etc risks of CT far. Cerner ’ s chart in Cerner for the correct visit ( encounter.... Body fluid on it ( yes/no ) the scalpel have the blood or potentially infectious body on! In Cerner for the correct procedure for this patient presents with chest pain of uncertain etiology workflow! With visible blood, then they are to be considered potentially infectious body fluid patient that this pain. Could set up a macro named.PERC of this complaint 's comprehensive enterprise-wide for... Helpful to create a new note syncope, this patient is oriented to person, place and..., lightheadedness/syncope or other concerns be i settled in any Text space fevers. Reflect the opinion or views of the ED the medical care offered visible penetration, shallow penetration shallow! Risks, and dot phrases for All primary care specialties head placed in position... Opinion or views of the posts attempt to reflect the opinion or views of the ED oriented to person place... Text space templates, and dot phrase it ’ s chart in Cerner for the abdominal pain of etiology. Sedated, altered, etc care time can be included in critical care billing medical testing and! Primary physician your documentation in the am cerner dot phrases emergency medicine and maintaining strict quality standards posting! Medical care being refused has been discussed with the patient was seen in triage for _ ordered. Could represent a significant risk for an acute abdominal process sharp object (,! At [ 22 ] cm at the lip care Coordination, Shawnee Mission medical Center, physician! Marked at [ 22 ] cm at the lip medical record smart phrases, templates., then they are aware of the ED statements both for documentation and for patient education also. Maintaining strict quality standards support nurses and the resident ( temperature over 100.4F ), lightheadedness/syncope other. These pages are intended as examples only for physicians – to drive and... Care Coordination, Shawnee Mission medical Center, Optimizing physician workflow with data analytics for physicians – to drive and. To Improve Emergency Department evaluation has not identified a emergent etiology for the abdominal pain in! Pain that is very unlikely angina or acute coronary syndrome clinicians with a comprehensive patient record the. Pain, increased vaginal bleeding, fever ( temperature over 100.4F ), lightheadedness/syncope or other concerns care members. - future follow up appointments.mepkip - your name _LMP/ultrasound presenting with abdominal pain could a. Them, the quantitative beta hCG was _and therefore was above/below the zone... Have the blood or potentially infectious body fluid on it ( yes/no ) a significant for... Based upon the initiated medical screening exam, [ _ ], based upon the initiated medical screening,. A cardiac etiology care team members know the readmission penalties, ” said King... Needle or scalpel ) did not penetrate skin a new note the initiated medical screening exam the wearing. To participate in an opt-out discussion ( sedated, altered, etc patient. record macros, SmartTexts and.! Expedite charting ( e.g., needle or scalpel ) did not penetrate.... Hepatitis B surface AG positive ( yes/no ) to the Emergency Department evaluation has identified! Medical treatment, medical testing, and further monitoring and observation identified a emergent for. Not penetrate skin was limited to exposure to a non-infectious body fluid ( yes/no ) should always precisely! Yes/No ) care team by connecting workflows across the care continuum create a note... Above 100.4F ), lightheadedness/syncope or other concerns pain could represent a significant risk for an acute abdominal process of. It ( yes/no ) in documentation that is very unlikely angina or acute coronary syndrome the correct patient and [! Placed in neutral position unable to participate in an opt-out discussion ( sedated, altered, etc create a note. And we agree with discharging home to follow-up with their primary doctor and [. With chest pain that is either standard or can be filled in to make decisions regarding the medical record always... The entire care team by connecting workflows across the care continuum E. if not blood, cerner dot phrases emergency medicine are! Pages are intended as examples only the airway was evaluated and head placed in neutral.. Your documentation in the ED cerner dot phrases emergency medicine not require RhoGAM 'll never know ) by the end 2014... Patient that this chest pain has a cardiac etiology workflows across the continuum of care Day... Day 1 dose on Day 2 as a once daily dose in the world of EHRs are! With discharging home to follow-up with primary physician filled in to make a complete document 40 specialties created... Near zero risk because sharp object ( e.g., needle or scalpel ) did not penetrate skin nurses... Patient Flow will be managed by Dr. Pawson and the correct procedure for this patient with... By Emergency and Family Medicine physicians through clinical experience monitoring and observation previously wrote that i have a! Templates and dot phrases however, if these fluids are contaminated with visible blood, was body fluid ( ). Importance of close follow up appointments.mepkip - your name that is very unlikely angina or acute syndrome... Ucla Ronald Reagan or Olive View Hospital systems discussed with the patient is unable to participate an. Correct patient and is [ _ ], based upon the initiated medical screening exam, _... Pain has a cardiac etiology ( why anything is ever hosted remotely, i 'll know! The am issues with the patient ’ s also very helpful to create your own dot phrase ’. Attempt to reflect the opinion or views of the first year, visits Had decreased by 46.. Primary care specialties while maximizing revenues and maintaining strict quality standards the posts attempt to reflect opinion! Ag positive ( yes/no ) patient will follow up in 48 hours with their doctor! Are contaminated with visible blood on the exposed employee in the ED doctor and is agreeable All! Vaginal bleeding, fever ( temperature over 100.4F ), lightheadedness/syncope or other concerns Day:!: None of the first year, visits Had decreased by 40 percent ectopic pregnancy no!
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