EPIC

The patient was brought to the ED by {TRANSPORT:107655}. The history is provided by the {Informant:200024}. @NAME@ is a @AGE@ @SEX@ who was in motor vehicle collision that occurred {time :105006}. @CAPHE@ was the {driver/ passenger :101688} who was {restraints :105004}, involved in a {type of crash :105005} motor vehicle accident at {speed :105007}. It is reported that the patient {list of things :105008}.

The patient currently has the following complaints: {:105009}. ***

The patient denies {ED MVA DENIES:109786}***

The patient's last tetanus vaccine was ***

Pre hospital information: {ED MVA PREHOSPITAL:105011}***.

. sahpigyn

The history is provided by the {Informant:200024}. @NAME@ is a @AGE@ pregnant*** @SEX@, G ***, P ***, A ***, with LNMP on *** presenting to the ED for ***

----------------------------------- REVIEW OF SYSTEMS ---------------------------------------

.rosbyage

Review of Systems

.sarosunable

A complete ROS is unable to be obtained due to ***.

--------------------------------------- PAST HISTORY --------------------------------------------

Past Medical History: .samed

Past Surgical History: .sasurg

Social History:

Tobacco Use: {USE:200014}

Alcohol Use: {USE:200014}

Drug use: {DRUG:200025}

Family History: .safam

Patient is unsure of the names of their current medications.

Allergies: Patient has no known allergies. ***

--------------------------------------- PHYSICAL EXAM ------------------------------------------

.vitalmulti = Vitals Recorded in This Encounter

***

.sapeschmidt

Constitutional: She appears well-developed and well-nourished. No acute *** distress.

Head: Normocephalic and atraumatic.

Eyes: PERRL. EOMI. No pale conjunctiva. No scleral icterus.

ENT: Mucous membranes are normal ***. Oropharynx is clear and symmetric ***.

Neck: Supple. No nuchal rigidity.

Cardiovascular: Regular rate. Regular rhythm. No murmurs. Distal pulses intact ***.

Pulmonary/Chest: No respiratory distress. Breath sounds normal ***. No wheezes, rales, or rhonchi.

Abdominal: Soft and nondistended. No *** tenderness. No rebound, guarding or rigidity. No organomegaly. Normal bowel sounds. ***

GU: No CVA tenderness ***.

Musculoskeletal: Moving all four extremities. No *** edema. No *** calf tenderness.

Skin: Warm and dry.

Neurological: Alert, awake and appropriate. Normal speech. Normal gait ***.

Psychiatric: Good eye contact. Appropriate in content/context. Normal affect.

.sapedodge (with additional focused exams)

Constitutional: She appears well-developed and well-nourished. No acute *** distress.

Head: Normocephalic and atraumatic.

Eyes: Conjunctivae are normal. PERRL.

HENT: Mucous membranes are normal ***.

(.sapeeyefull )

Eyes:

Visual Acuity: Right eye: 20/***. Left eye: 20/***.

External: No edema or erythema of the eyelid. No*** conjunctival injection or edema. Normal sclera. No drainage. No proptosis. The lid was everted***.

Ocular Motility: EOMI. Conjugate gaze.

Pupils: PERRL. Pupils equal and reactive *** mm to *** mm bilaterally without direct or consensual photophobia. No Afferent Pupillary Defect.

Visual Fields: Intact***.

Intraocular Pressure: Right eye: *** mmHg. Left eye: *** mmHg.

Ophthalmoscopic exam: Discs margins are sharp***. No papilledema***.

Slit Lamp Exam: Clear anterior chamber. No hyphema. No*** corneal abrasions. No corneal ulcerations. No*** foreign body was found. No*** cell and flare.

Fluorescein Uptake: Fluorescein strip was used. No*** fluorescein uptake.

Neck: Supple.

Cardiovascular: Regular rate. Regular rhythm. No murmurs. Distal pulses intact ***.

Pulmonary/Chest: No respiratory distress. Breath sounds normal ***. No wheezes, rales, or rhonchi.

Abdominal: Soft. No *** tenderness. No guarding or rebound.

(.sapepelvic)

Pelvic: Female chaperone present. Normal external inspection. No lesions visible on labia majora or minora. Cervical os is closed. There is no*** cervical motion tenderness. No*** blood in the vaginal vault. No*** discharge. No*** uterine tenderness. No*** adnexal tenderness or masses. Swabs taken for wet prep and Gonorrhea and Chlamydia***.

Musculoskeletal: No *** edema.

Skin: Warm and dry.

Neurological: She is alert and oriented ***. No acute focal neurological deficits are appreciated.

Psychiatric: She has a normal mood and affect.

.sapepeds

Constitutional: Active. {Distress:109333} distress. Non-toxic. Well hydrated and well appearing. Attentive, interactive, and appropriate for age. No evidence of lethargy or irritability. ***Cries normally with tears on exam, but is quickly consolable. ***Smiling and playful.

Head: Normocephalic, atraumatic.

Ears: Right TM is unremarkable***. Left TM is unremarkable***.

Nose/Throat: Moist mucous membranes. Symmetric palate. Posterior pharynx is clear***, no exudates. No palatal petechiae.

Eyes: PERRL. Conjunctivae are normal. No scleral icterus.

Neck: Neck is supple. No meningismus.***

Lymphatic: No {ED LYMPH DEFAULTS:101543}

Cardiovascular: Normal*** rate. Regular rhythm. No murmurs. Well perfused.

Pulmonary/Chest: Exhibits no retraction, nasal flaring***, or grunting***. No respiratory distress. Breath sounds are clear bilaterally***. No stridor, wheezes, rales, or rhonchi.

Abdominal: Soft and non-distended. No crying or grimacing with deep abdominal palpation. .

Musculoskeletal: Moves all four extremities. Brisk capillary refill.

Skin: Skin is warm and dry. No bruising. No rashes***. No petechiae. No purpura.

Neurological: Alert and interactive***. Moves all extremities. Age appropriate behavior.

.sapetraumaminor

Constitutional: {Distress:109333} distress. Awake, alert, and appropriate.

Head: Atraumatic***.

Eyes: PERRL. EOMI. No conjunctival injection.

Mouth/Throat: Airway intact. Mucous membranes are moist.

Neck: Trachea midline. No cervical midline bony tenderness, deformities, or step-offs.

Cardiovascular: Normal rate***. Regular rhythm. Heart sounds normal***. Distal pulses are equal and 2+.

Pulmonary/Chest: Lungs are clear bilaterally***. No decreased breath sounds. No external*** evidence of trauma to the chest. Chest wall is stable and ***non-tender.

Abdominal: No distension. Soft. No*** tenderness to palpation.

Genitourinary: No*** CVA tenderness. No flank ecchymosis***.

Back: No*** midline bony tenderness, deformities, or step-offs of the thoracic or lumbar spine.

Musculoskeletal: Pelvis stable. No*** deformities. Full ROM in all extremities***.

Skin: Normal color. No*** lacerations.

Neurological: Alert and appropriate. GCS score is 15***. There is equal 5/5 strength in the bilateral upper and lower extremities***.

Psychiatric: Normal affect.

.sapetraumasevere

Primary Survey

Airway: {TRAUMA A:109042}

Breathing: {TRAUMA B:109043}

Circulation: {TRAUMA C:109044}

Spine precautions: {TRAUMA D:109045}

Total Glascow Coma Scale: {:109715}

Eyes: {GCS EYE OPENING:108077}

Verbal: {GCS - VERBAL RESPONSE:108078}

Motor: {GCS - MOTOR RESPONSE:108079}

Secondary Survey

Constitutional: {ED CONSTITUTIONAL EXAM:200000}

Head: Atraumatic***. No cephalohematoma. Midface is stable. No Raccoon eyes. No Battle's sign.

Eyes: PERRL. Pupils are *** mm to *** mm bilaterally. EOMI. No conjunctival injection.

Ears: No*** hemotympanum.

Nose: No nasal deformity. No*** septal hematoma.

Mouth/Throat: Airway intact. No malocclusion. No dental injury. ***

Neck: C-collar in place***. Trachea midline. No *** cervical midline bony tenderness, deformities, or step-offs.

Cardiovascular: Normal rate***. Regular rhythm. Heart sounds normal***. Peripheral pulses are 2+ in all extremities.

Pulmonary/Chest: Lungs are clear bilaterally***. No decreased breath sounds. No external*** evidence of trauma to the chest. Chest wall is stable and ***non-tender. No crepitus. No flail segment. No asymmetric rise.

Abdominal: No distension. Soft. No*** tenderness to palpation. No external evidence of abdominal trauma.

Genitourinary: No evidence of genital injury***.

Back: No*** midline bony tenderness, deformities, or step-offs of the thoracic or lumbar spine. No*** abrasions or ecchymosis

Rectal: No*** gross blood.

Musculoskeletal: Pelvis stable to compression and *** non tender.

RUE: No*** deformities. Full ROM***. There is no bony*** tenderness.

LUE: No*** deformities. Full ROM***. There is no bony*** tenderness.

RLE: No*** deformities. Full ROM***. There is no bony*** tenderness.

LLE: No*** deformities. Full ROM***. There is no bony*** tenderness.

Skin: Normal color. No*** lacerations.

Neurological: GCS score is ***. Strength is 5/5 in upper and lower extremities bilaterally. *** Distal sensation grossly intact ***. {TRAUMA NEURO:109134}

Psychiatric: Normal affect.

---------------------------------- ED COURSE IN TRAUMA BAY-------------------------------

Time: ***. The initial vital signs are: BP ***, HR ***, SpO2 ***, RR ***

Consultations: Trauma is at bedside and assisted with evaluation and formulation of plan. ***

Consultations: 12:14 PM. Dr. *** {ED CONSULTANT LIST BRIEF:200116}. Indication for consultation: *** Recommendations: ***

.samdmcomplexwlabs (Pulls EVERYTHING below in) Option for .samdmcomplexwlabs, .samdmcomplexnolabs, .samdmcomplexresident

---------------------------------- LABORATORY RESULTS -----------------------------------

***

.edlabs

-------------------------------------- PROCEDURE ------------------------------------------------

.edproc

PROCEDURE NOTE: Initial Fracture Care

{ED PROCEDURE LIST OF ALL SMARTTEXTS:114539}

Informed consent, after discussion of the risks, benefits, and alternatives to the procedure, was obtained verbally from the patient prior to procedure.

The patient was identified using two patient identifiers: {ED UNIVERSAL PROTOCOL YES UNABLE:116181}.

The H&P along with required diagnostics are available in Epic: Yes

The correct procedure was verified: Yes

Procedural site identified: Yes

Presence of required equipment verified prior to starting procedure: Yes

Patient allergies identified or reviewed: Yes

Site marking done: Not indicated

A timeout to verify the correct patient, procedure, and site was performed immediately prior to the procedure

The patient had a fracture of the Left distal fibula. The fracture was not displaced and did not require manipulation for current care

The fracture was appropriately immobilized and was neurovascularly intact at discharge.

Dr. Emily Dodge.

PROCEDURE NOTE: SPLINTING

Informed consent, after discussion of the risks, benefits, and alternatives to the procedure, was obtained verbally from the patient prior to procedure.

The patient was identified using two patient identifiers: Yes.

The H&P along with required diagnostics are available in Epic: Yes

The correct procedure was verified: Yes

Procedural site identified: Yes

Presence of required equipment verified prior to starting procedure: Yes

Patient allergies identified or reviewed: Yes

Site marking done: Not indicated

A timeout to verify the correct patient, procedure, and site was performed immediately prior to the procedure

The area to splint was appropriately positioned. A {ED SPLINTS:102177} was {ED SPLINTS PERFORMANCE:102178::"applied"}. The patient tolerated the procedure well. The splinted body part was neurovascularly unchanged following the procedure.

*** Dr. Emily Dodge.

Document fracture care for all fractures***

The procedure was performed by the emergency physician resident, {ED RES:102248}.

(.Edpp) - I was personally present for the key and critical portions of the procedure.***

The procedure was performed by the emergency physician resident, {ED RES:102248}.

I was not present for the key and critical portions of the procedure.***

------------------------------------------ ED COURSE ---------------------------------------------

.sahipaa - HIPAA: Verbal permission granted from patient to discuss case , including protected health information, in front of family / friends in room at the time of the evaluation.***

ED Medications:*** .edmeds

Medications

sodium chloride 0.9 % infusion (not administered)

nitroglycerin (NITROSTAT) sublingual tablet (not administered)

aspirin tablet (325 mg Oral Given 2/28/19 0030)

***

.sanow (time)

.samdmreevaluation - @EDNOW@. Re-evaluation. The patient ***

*** *** was given follow up instructions and expressed understanding of outpatient plan.

.edsmoke I have provided {NUMBERS 1-11 AND 15:107513} minutes of smoking cessation counseling to this patient including

{EDSMOKINGINTERVENTIONS:116436}

The patient indicated that he/she {WAS/WAS NOT:115938::"was not"} interested in the {EDsmokinginterventionspatient:116437}

.ednonarc

{ED reasons pain meds not given:116863}

@EDCOURSE@ ***

.edblood

Attestation of Informed Consent for Blood and/or Blood Components

The transfusion of blood and/or blood components were discussed with the patient and/or legal representative at ***. The risks, benefits and alternatives were reviewed. Questions regarding blood transfusions were answered. The patient / or the patient's legal representative agree with the plan for transfusion of blood and/or blood components.

Dr. Emily Dodge.

.edthrive

The patient was informed about the availability of a Thrive Peer supporter for substance use disorder in the ED. Patient agrees to speak with an Thrive peer supporter.

Dr. Emily Dodge.

.edreport - HAVE TO HAVE WITH ADMISSIONS.

ED Provider Transfer of Care Admission Report:

Clinical Impression: ***

Reason for admission: ***

Interventions performed in ED: ***

Pending labs: {ed signout labs:111783}

Pending imaging results: {ED SIGNOUT STUDIES:111784}

Patient condition: {CLINICAL COURSE - ASSESSMENT:18}

Report called to ***, *** senior

Dr. Emily Dodge.

--------------------------------- MEDICAL DECISION MAKING -------------------------------

Vital Signs: Reviewed the patient’s vital signs.

Nursing Notes: Reviewed and utilized the nursing notes.

Interpreter: {ED INTERPRETER USE:400220}

Old Medical Records:

The patient's available past medical records and past encounters were reviewed. Summary of pertinent elements include: ***

The patient has a past medical history of ***

The patient was seen on ***

Care Everywhere was accessed. The records show: ***.

There are no old records available within Epic***

.oarrs

(when your physician says “narx check is …” “narcotics score of…” “overdose risk score of… “ )

@OARRSREVIEWED@ The records show: ***

Laboratory Studies: Ordered and independently reviewed the laboratory tests. Pertinent results include:

CBC- (.cbcnormal) No clinically significant leukocytosis or anemia.

BMP- *** (.bmpnormal) No clinically significant electrolyte abnormality or renal insufficieny.

LFTs- unremarkable.

Lipase- wnl. *** value.

I-Stat Troponin- ***, negative.

D-dimer- negative or not elevated.

Urinalysis- no evidence of infection.

Urine HCG- negative. OR. She is pregnant. OR She is not pregnant.

***ED Bedside Focused Ultrasound:

Performed *** ultrasound with the following results: ***.

See imaging tab for complete report.

Radiology Studies: Ordered and reviewed the radiology images.

Reviewed the radiologist's preliminary report which reads as follows: ***

Reviewed the radiologist's final report which reads as follows: ***

I independently reviewed the images and agree with the radiologist's report. ***

EKG: Ordered, reviewed, and independently interpreted the EKG.

Time Performed: ***

{ED EKG INTERPRETATION:101569::"NSR, rate of ***, nl axis, normal intervals, no ST-T wave changes"}

Comparison: {ED EKG COMPARISON SCRIBE NOTE:116128}

Consultations: Time: ***. Indication for consultation: ***

Spoke with {ED CONSULTANT LIST BRIEF:200116}. Discussed case. The consult {ED CONSULTATION SCRIBE LIST:116120}.

Additional Medical Decision Making: ***

{ED Notewriter Documentation Tools:120522}:

[] blood (If blood is given)

[] stroke / tia / SAH

[] Restraint (If put in restraints.)

[] Sepsis

[] Critical Care

[] Timi Score (for NSTEMI)

[] Cath lab times

[] Low Risk CP documentation

[] Therapeutic Hypothermia

[] PORT (.edport)

[] NIH (.edscoreNIH)

[] HEART Score

------------------------------ IMPRESSION AND DISPOSITION -----------------------------

IMPRESSION (aka- Diagnosis.)

***

.eddx NSTEMI (non-ST elevated myocardial infarction) (HCC) [302807]

Medical Screening Exam: The patient has received a medical screening examination and within reasonable clinical confidence {ED MSE 4:109529}

DISPOSITION

Disposition: {ED DISPOSTION SCRIBE:116123}

Patient condition: {ED DISCHARGE CONDITION:114493::Stable}

-------------------------------------- COUNSELING ------------------------------------------------

ED Prescriptions:***

.edptmedstart= New Prescriptions

.edptmedchange *** (will pull in prescriptions that were modified)

Counseling: Spoke with the {FAMILY:106584::patient} and discussed today’s findings, in addition to providing specific details for the plan of care and counseling regarding the diagnosis and prognosis. {HE/SHE:100161} was given the opportunity to ask questions.

Discussed the return indications and importance of follow-up.

Advised to follow-up with ***.

Advised to return to the ED for ***.

Instructed to call back for the Gonorrhea and Chlamydia results.

Advised to quit smoking.

Educated on the common potential side effects of medication to be prescribed.

Discussed the plan for admission.

Discussed the plan to monitor in CDU.

------------------------------------- SCRIBE ATTESTATION ------------------------------------

@TD@, @NOW@.

This note is prepared by @ME@ acting as Scribe for Dr. {ED STAFF:102242}

All medical record entries made by the Scribe were at my direction and personally dictated by me. I have reviewed the chart and agree that the record accurately reflects my personal performance of the history, physical exam, assessment, plan, and diagnosis. I have also personally directed, reviewed, and agree with the discharge instructions.

Dr. {ED STAFF:102242}. ***

From the Door Exam:

FTD From the door exam:

(.sapewallisFTD …. Can use this dot phrase for any physician.)

Constitutional: Well developed, well nourished. Awake & alert. No distress.

Head: Atraumatic.

Eyes: Pupils equal and round. No injected conjunctivae. No scleral icterus.

ENT: Mucous membranes are moist.

Neck: Normal movement.

Cardiovascular: Well perfused.

Pulmonary/Chest: No evidence of respiratory distress. No accessory muscle use. Speaking in full sentences.

Abdominal: Soft and non-distended.

Musculoskeletal: Moves all four extremities. No deformities.

Skin: Skin is warm and dry. No rashes on exposed skin.

Neurological: Alert, awake, and appropriate. Normal speech.

Psychiatric: Good eye contact. Appropriate in content/context. Normal affect.

Full Exam- Example (Dr. Dodge.)

Example: .sapedodge

Constitutional: She appears well-developed and well-nourished. No acute *** distress.

Head: Normocephalic and atraumatic.

Eyes: Conjunctivae are normal. PERRL.

HENT: Mucous membranes are normal ***..