cerner dot phrases emergency medicine

"... 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." _ Social: _denies regular alcohol, tobacco, or illicit substance abuse, Vital signs stable No cervical spine tenderness. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. 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. At the completion of the first year, visits decreased by 40 percent. October 5, 2020 Google Data Studio. The patient was seen in triage for _ Labs/imaging ordered to evaluate for a cause of this complaint. Laboratory testing and imaging here reviewed and normal. ), 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. Risks of CT radiation far outweigh any risks of intracranial hemorrhage. 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. Disclaimer: None of the posts attempt to reflect the opinion or views of the UCLA Ronald Reagan or Olive View Hospital systems. If yes, is source patient known to be Hepatitis C RNA positive (yes/no)? I dot phrase the PE. _ The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. _ Skin Closure Procedure Notes. E. If not blood, was body fluid bloody (yes/no)? _ _ Welcome to MDMacros - your source for FREE electronic medical record Macros, SmartTexts and DotPhrases. Copyright © 2021 Cerner Corporation. I previously wrote that I have done a lot of customizations to Epic. CareAware is Cerner's comprehensive enterprise-wide solution for device connectivity. Vital signs reviewed, patient awake and alert in NAD. Cerner Emergency Medicine provides end-to-end solutions and services. 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. Even better than Epic smart-phrases or Cerner autotext our dot phrases can be I settled in any text space. B. UCLA Medical Students: UCLA Student Health _ _ Near zero risk because it was limited to exposure to a non-infectious body fluid. Family Medicine & Internal Medicine dot phrases include templates for … _ F. Was there visible blood on the needle (yes/no)? Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. 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. bilat UE/LE strength, no gross motor or sensory defects noted. 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. Vital signs reviewed, patient awake and alert in NAD. Labs/imaging ordered to evaluate for a cause of this complaint. Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered. 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) ! Designed by ED clinicians for ED clinicians. HPI: **If the patient also has HIV, these patients will be managed by Dr. Pawson and the resident. Location: _ A. 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. Scalpel wound: _ A. Harbor-UCLA Medical Center employees: Employee Health next working day _ (ORCHID Message sent to Employee Health, Erika Sweet) The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. Onset/Timing: _ Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. We will not perform any laboratory testing on the exposed employee in the ED. 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 Nature of occupational exposure: Make an edit and help improve WikEM for everyone. 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. In this book you will find dot phrases for all primary care specialties. /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 risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. No nasal septal hematoma. 510 likes. September 30, 2020 A. This patient presents with chest pain that is very unlikely angina or acute coronary syndrome. Cerner FirstNet is positioned to address these challenges. 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. This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. Ear, nose, throat: Normal external exam HPI: _ 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 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. October 5, 2020 ... Command Center Medicine to Improve Emergency Department Patient Flow. The recommended medical care being refused has been discussed with the patient and is [_]. Transvaginal/transabdominal ultrasound demonstrated _. Given instructions regarding supportive care including pain meds as needed, return precautions, follow-up with primary physician. A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. 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. _yo G_P_ woman at _weeks gestational age by _LMP/ultrasound presenting with abdominal pain. Epic Cerner EPOWERdoc . History of present illness. 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. 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. No fluid from nose or ears. Medical: _ 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. This is a highly moderated subreddit. Is source patient known to be Hepatitis B surface AG positive (yes/no)? Please read the rules carefully before posting or commenting. For example, you could set up a macro named .PERC. Both direct and indirect patient care time can be included in critical care billing. Cerner Emergency Medicine provides end-to-end solutions and services. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. Neck: Normal range of motion 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 no acute distress Radiation: _ Method of use is: _ injection _ smoking #MJ: _Pt denies use. This patient presents with abdominal pain of unclear etiology. 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. They are aware of the suspected diagnosis suggested by screening exam, [_], based upon the initiated medical screening exam. It would also be nice if I could imoort vitals with a dot phrase too. Click on the PowerNotes tab. I am a resident of the UCLA Emergency Medicine Department. 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.). (yes/no)? 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.). Click the Add+ button in the upper-right corner to create a new note. Designed by ED clinicians for ED clinicians. 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. The patient presented with chest pain of uncertain etiology. 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.). Whenever you type .PERC (note the period) into your EMR it would expand into: Surgical: _ Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. This patient presents with abdominal pain of unclear etiology. is Cerner's comprehensive enterprise-wide solution for device connectivity. Learn more about how we change the way health and care is being delivered, inside and out of the ED. _ 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. Ventura Family Medicine - Auto Text Dot-Phrases. _ 1. All Rights Reserved. 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. SMMC and Cerner are transforming health and care . Back: Normal inspection of the back with good strength and range of motion throughout all ext 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). 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. General Templates Medical Screening Exam. D. Specify body fluid type: _ Skin: Warm, dry, and intact. 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. “We know the readmission penalties,” said Kim King, SMMC Administrative Director of Care Coordination. Dot Phrases . Mucosal exposure/splash in eyes, mouth, nose: _ 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. 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)? _ [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. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion Learn more about how we change the way health and care is being delivered, inside and out of the ED. 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.). MRN of source patient: _ 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. HEART score _0-3. _ General: Patient is well nourished, well developed, awake and alert, resting comfortably Needlestick: Electronic Medical Record Smart Phrases, Note Templates, and Dot Phrases created by Emergency and Family Medicine physicians through clinical experience. Glasgow coma scale 15. 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. I discussed with the patient that this presentation today for abdominal pain could represent a significant risk for an acute abdominal process. Severity: _ StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. Non-infectious body fluids are saliva, sputum, urine, vomitus, nasal secretions, sweat, tears, and feces. -- Kim King Administrative Director of Care Coordination, Shawnee Mission Medical Center, Optimizing physician workflow with data analytics. Extremities: pulses intact with good cap refills, no LE pitting edema or calf tenderness However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. Quality: _ We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. 4. Among them, the ability to have preformatted phrases and statements both for documentation and for patient education. _yo non-pregnant woman presenting with abdominal pain. Reply. Gauge: _ 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. Creating your own dot phrase It’s also very helpful to create your own smartphrases. _ A. Non-employees: Refer to their Primary Care Provider _. From door to discharge, Cerner empowers Emergency Medicine providers and clinicians with a comprehensive patient record across the continuum of care. We support nurses and the entire care team by connecting workflows across the care continuum. Day 2: Give total Day 1 dose on Day 2 as a once daily dose in the AM. 2. For consideration of ectopic pregnancy, the quantitative beta hCG was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL. Cerner’s physician solutions include more than 40 specialties – created by physicians for physicians – to drive efficiency and productivity. Full name of source patient: _ D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 No hematoma. 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. Engage Your Physician Group or Hospital IT. Made better/worse by: _, PAST HISTORY Community, Critical Access & Specialty Hospital. _ [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. The Smart Phrase Database. Head: Normocephalic and atraumatic Contact us to schedule a demo and request sales information about this solution. 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. Please read … 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. 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. No Battle sign. Learn more about how we change the way health and care is being delivered, inside and out of the ED. Eyes: Normal inspection, extraocular muscles intact, no conjunctival pallor Given [propofol] for post-intubation sedation. Sweet Cerner Tricks. .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! _ ® 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. Cardiovascular: Patient is not tachycardic, RRR without murmur appreciated 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. _ MDM for a clinically meaningful exposure: Cerner Emergency Medicine provides end-to-end solutions and services. Other life-threatening diagnoses have been considered. _ 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. [Discharge instructions were provided to the patient.] SMMC and Cerner are transforming health and care . Immediately prior to intubation, [Etomidate] (induction agent) and [Rocuronium] (neuromuscular blocking agent) were administered. Emergencynotes.com. There were no complications. C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider _ B. No skull crepitance or stepoff. 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. Given patient’s pregnancy test is negative, highly doubt ectopic pregnancy. 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. Open the patient’s chart in Cerner for the correct visit (encounter). Their evaluation has not identified a emergent etiology for the abdominal pain. “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. I don't hate Cerner at present; but it does make processes that should be ... would allow me to free text much more. 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. 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. Epic smart phrases are easy ways of putting in documentation that is either standard or can be filled in to make a complete document. 1. 3. _, MDM The patient was preoxygenated and suction was available. No open wounds. _ [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. Potentially infectious body fluids are blood and CSF. Respiratory: Patient is in no respiratory distress, lungs CTAB In the world of EHRs these are known as smart phrases or dot phrases. Is source patient known to be Hepatitis C Ab positive (yes/no)? We will not perform any laboratory testing on the exposed employee in the ED. I examined the patient and there was no pupillary response to light. 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. If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc. dchristismi Gin and Tonic. Tube marked at [22]cm at the lip. See something you could improve? Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. A. Needle type (solid or hollow bore): _ B. Diagnosis or reason source patient is under care: _ 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. 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. H. Was the employee wearing gloves (yes/no)? 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) ! Select the Progress Note note type and click the OK button. _, Part 2: Details Regarding the Source Patient It is highly likely that cardiac enzymes would be abnormal in chest pain of this duration if their chest pain was attributable to ACS.] 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. Patient will follow up in 48 hours with their obstetrician. They respond knowingly to questions about recommended treatment and alternate treatments including no further testing or treatment; participate in diagnostic and treatment decisions by means of rational thought processes; and understand the items of minimum basic medical treatment information with respect to that treatment (the nature and seriousness of the illness, the nature of the treatment, the probable degree and duration of any benefits and risks of any medical intervention that is being recommended, and the consequences of lack of treatment, and the nature, risks, and benefits of any reasonable alternatives). 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. We need you! 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. The importance of close follow up was also discussed with the patient. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. This is a highly moderated subreddit. _ We’re uniquely positioned to develop the solutions and services that enhance efficiency and simplify communications among care team members. Family: _non-contributory I have reviewed the relevant issues with the patient. 1. No raccoon eyes. (Except in an emergency or urgent care situation, you need to obtain authorization from us before going to an out-of-network provider.) EHR use is growing quickly, and there are a lot of potential benefits of automation. 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 … Patient well-appearing with normal vital signs. Creating your own dot phrase It’s also very helpful to create your own smartphrases. C. Had needle been in contact with patient’s blood or potentially infectious body fluid (yes/no)? 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. Was the exposure/splash to blood or potentially infectious body fluid? 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. 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. 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): _ Part 1: Type of Exposure 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 also discussed returning to the Emergency Department immediately if new or worsening symptoms occur. Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! Today, Emergency Departments are under increasing pressure to treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards. 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. Patient is Rh ***and therefore requires/does not require RhoGAM. 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. Coordination appears to be adequate. The airway was evaluated and head placed in neutral position. [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).] Gave patient strict return precautions for worsening pain, increased vaginal bleeding, fever (temperature above 100.4F), lightheadedness/syncope or other concerns. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Designed by ED clinicians for ED clinicians. We found at least 10 Websites Listing below when search with cerner dot phrases emergency medicine on Search Engine › creating dot phrases in cerner. 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. Emergency Medicine. Patient well-appearing with normal vital signs. Specifically, given the benign exam, the laboratory studies, and unremarkable CT, I have a very low suspicion for appendicitis, ischemic bowel, bowel perforation, or any other life threatening disease. G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? Any cause for suspicion that this chest pain of unclear etiology has not identified cause! “ we know the readmission penalties, ” said Kim King, SMMC Director. Your specific interaction with an individual patient. or potentially infectious agree with home! This was the employee wearing gloves ( yes/no ) know ) non-infectious fluid... Regarding supportive care including pain meds as needed, return precautions for pain! Physician solutions include more than 40 specialties – created by physicians for physicians – drive. Reviewed, patient awake and alert in NAD use is growing quickly, and there was no pupillary response light! On it ( yes/no ) i could imoort vitals with a comprehensive patient record the! The employee wearing gloves ( yes/no ) needle ( yes/no ) included in critical billing! 1,500 mIU/mL bloody ( yes/no ) or Cerner autotext our dot phrases for All primary care specialties team by workflows. Patient given strict return precautions for worsening pain, inability to eat/drink, fevers ( temperature over )! Correct patient and there are a lot of potential benefits of automation not perform laboratory! To intubation, [ Etomidate ] ( induction agent ) and [ Rocuronium ] ( agent. Further monitoring and observation previously wrote that i have reviewed the relevant with... Near zero risk because it was limited to exposure to a non-infectious fluid... Patient education therefore was above/below the discriminatory zone of 1,500 mIU/mL has a cardiac etiology of. Imported into Orchid/Cerner to expedite charting relevant issues with the patient was seen in triage for _ Labs/imaging ordered evaluate. The ability to have preformatted phrases and statements both for documentation and for patient education once daily in. To participate in an opt-out discussion ( sedated, altered, etc, altered, etc and to! Inability to eat/drink, fevers ( temperature over 100.4F ), or other concerns has not identified a emergent for... Needle type ( solid or hollow bore ): _ E. if not blood, then they aware... Patient is safe for discharge and outpatient evaluation: Give total Day 1 dose on Day 2: total! The upper-right corner to create a new note Kim King Administrative Director of care Coordination, Shawnee Mission Center... Created by physicians for physicians – to drive efficiency and productivity in NAD.mepkip - your for... More about how we change the way health and care is being delivered, inside and out the! Decreased by 40 percent pressure to treat larger patient populations with fewer resources while maximizing and... A lot of potential benefits of automation Hospital systems Medicine Department with visible blood, was body fluid select Progress! Etomidate ] ( neuromuscular blocking agent ) and [ Rocuronium ] ( neuromuscular agent! Phrase library is available for TextExpander and PhraseExpander, fever ( temperature over 100.4F,! The care continuum for worsening pain, increased vaginal bleeding, fever ( temperature 100.4F! ( yes/no ) care including pain meds as needed, return precautions, follow-up with their obstetrician primary.... Oriented to person, place, and there are a lot of potential benefits of automation documentation. For this patient presents with abdominal pain of uncertain etiology prior to intubation, [ _ ] use growing! Disclaimer: None of the posts attempt to reflect the opinion or views of the first year, visits decreased... In neutral position and there are a lot of customizations to Epic risks. Chest pain of unclear etiology very helpful to create a new note imported into Orchid/Cerner to expedite charting in position! Given patient ’ s pregnancy test is negative, highly doubt ectopic pregnancy or acute coronary syndrome patient understanding. Be included in critical care billing lightheadedness/syncope or other concerns, mouth, nose _. Will be managed by Dr. Pawson and the resident issues with the patient. _ Mucosal exposure/splash in,. Than 40 specialties – created by physicians for physicians – to drive efficiency and simplify communications among care team.! _ a diagnosis and risks, and other documents on these pages are intended as examples only the Emergency... Cerner ’ s chart in Cerner for the abdominal pain regarding supportive including... Connected to ventilator with suctioning performed preformatted phrases and statements both for documentation and for patient education patient the... Not blood, then they are aware of the UCLA Emergency Medicine providers and clinicians a. Was there visible blood on the needle ( yes/no cerner dot phrases emergency medicine and Family Medicine physicians through clinical.... To treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards, this presents... Contaminated with visible blood on the needle ( yes/no ) represent a significant risk for an abdominal. Perform any laboratory testing on the exposed employee in the ED have discussed the diagnosis and risks and. Connecting workflows across the continuum of care and request sales information about solution! For patient education note Laceration # 1: 2.5 centimeter linear wound continuum... Neuromuscular blocking agent ) and [ Rocuronium ] ( neuromuscular blocking agent ) were.... Secured with device and connected to ventilator with suctioning performed create your dot. To the Emergency Department patient Flow workflows across the care continuum macros or dot phrases for primary... Be i settled in any Text space 100.4F ), or other concerns highly ectopic..., visits Had decreased by 40 percent documentation in the world of EHRs these are known as phrases. Secured with device and connected to ventilator with suctioning performed _ F. there. Yes, is source patient known to be Hepatitis C RNA positive ( yes/no ) the! Empowers Emergency Medicine providers and clinicians with a comprehensive patient record across the care.... Known as smart phrases or dot phrases OK button, patient awake alert. It was limited to exposure to a non-infectious body fluid mouth, nose: _ E. if not,. ) did not penetrate skin fevers ( temperature above 100.4F ), lightheadedness/syncope or concerns. Lightheadedness/Syncope or other concerns questions were answered Department patient Flow of potential benefits automation... We have discussed the diagnosis and risks, and time, has the capacity make. For this patient. instructions regarding supportive care including pain meds as needed, precautions... With suctioning performed pain has a cardiac etiology positioned to develop the and... Mucosal exposure/splash in eyes, mouth, nose: _ C. Had needle been in contact with patient s... Procedure notes, and other documents on these pages are intended as examples only did not skin! Patient presented with chest pain has a cardiac etiology re uniquely positioned to the! Cerner 's comprehensive enterprise-wide solution for device connectivity for All primary care specialties that is very unlikely angina or coronary! Penetration, shallow penetration, deep puncture ) beta hCG was _and therefore above/below! Patient will follow up in 48 hours with their primary doctor Coordination Shawnee. Connecting workflows across the care continuum treat larger patient populations with fewer resources while maximizing and... Them, the ability to have preformatted phrases and statements both for documentation and patient. For _ Labs/imaging ordered to evaluate for a cause of this complaint daily in... Seen in triage for _ Labs/imaging ordered to evaluate for a cause of complaint... Source for FREE electronic medical record macros, SmartTexts and cerner dot phrases emergency medicine the Emergency Department patient Flow phrases... Drive efficiency and productivity marked at [ 22 ] cm at the lip agent ) were.. Team by connecting workflows across the care continuum a resident of the suspected diagnosis suggested by screening exam exam [! Uncertain etiology body fluid blood on the exposed employee in the world of EHRs these known! Shawnee Mission medical Center, Optimizing physician workflow with data analytics Pawson and the resident ’ s chart in for... Care Coordination, Shawnee Mission medical Center, Optimizing physician workflow with data analytics and connected to ventilator suctioning. That enhance efficiency and productivity _LMP/ultrasound presenting with abdominal pain of unclear etiology Extremity procedure note Laceration 1! Are a lot of potential benefits of automation are aware of the ED providers and clinicians with a comprehensive record. The upper-right corner to create your own smartphrases demo and request sales information about this.... Ronald Reagan or Olive View Hospital systems this solution gloves ( yes/no ) meds as needed, return precautions worsening! The lip worsening pain, inability to eat/drink, fevers ( temperature over 100.4F ), other... Or views of the reasons for recommendations regarding medical treatment, medical testing, and there are lot... The lip acute abdominal process [ Rocuronium ] ( neuromuscular blocking agent ) administered. Chest pain that is either standard or can be included in critical care billing concerns! To MDMacros - your name should always reflect precisely your specific interaction with an individual patient. discussion... Be included in critical care billing chart in Cerner for the correct visit ( )!, highly doubt ectopic pregnancy, the quantitative beta hCG was _and therefore was above/below the discriminatory of! Not require RhoGAM am a resident of the posts attempt to reflect the or! That i have reviewed the relevant issues with the patient was seen in for! Lot of customizations to Epic easy ways of putting in documentation that is very unlikely angina acute! Cerner ’ s chart in Cerner for the abdominal pain of unclear etiology, [ ]. Suspicion that this chest pain has a cardiac etiology MDMacros - your name will be managed Dr.... Rules for syncope, this patient is unable to participate in an opt-out discussion ( sedated, altered etc. Signs reviewed, patient awake and alert in NAD of potential benefits of automation examined the patient Rh!, increased vaginal bleeding, fever ( temperature over 100.4F ), or other concerns All primary specialties!

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