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 cords were directly visualized using a [size 3 MacIntosh blade] and a [7.5mm] cuffed endotracheal tube was placed via the orotracheal route. Skin: Warm, dry, and intact. [Discharge instructions were provided to the patient.] Day 2: Give total Day 1 dose on Day 2 as a once daily dose in the AM. _ Potentially infectious body fluids are blood and CSF. 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. A. Family Medicine & Internal Medicine dot phrases include templates for … Creating your own dot phrase It’s also very helpful to create your own smartphrases. No nasal septal hematoma. Even better than Epic smart-phrases or Cerner autotext our dot phrases can be I settled in any text space. 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. F. Was there visible blood on the needle (yes/no)? Cerner FirstNet is positioned to address these challenges. Emergency Medicine. See something you could improve? _ HPI: Please read … This patient presents with abdominal pain of unclear etiology. This patient presents with chest pain that is very unlikely angina or acute coronary syndrome. B. UCLA Medical Students: UCLA Student Health _ Labs/imaging ordered to evaluate for a cause of this complaint. Today, Emergency Departments are under increasing pressure to treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards. We’re uniquely positioned to develop the solutions and services that enhance efficiency and simplify communications among care team members. 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. A. Needle type (solid or hollow bore): _ We will not perform any laboratory testing on the exposed employee in the ED. Diagnosis or reason source patient is under care: _ _ I am a resident of the UCLA Emergency Medicine Department. Other life-threatening diagnoses have been considered. This is a highly moderated subreddit. 1. We found at least 10 Websites Listing below when search with cerner dot phrases emergency medicine on Search Engine › creating dot phrases in cerner. 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. “We know the readmission penalties,” said Kim King, SMMC Administrative Director of Care Coordination. 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. 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. Patient will follow up in 48 hours with their obstetrician. The airway was evaluated and head placed in neutral position. _, MDM Neck: Normal range of motion 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. Patient well-appearing with normal vital signs. (Except in an emergency or urgent care situation, you need to obtain authorization from us before going to an out-of-network provider.) Cerner Emergency Medicine provides end-to-end solutions and services. The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. 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. The recommended medical care being refused has been discussed with the patient and is [_]. This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. While there are multiple EHRs, Epic has been adopted most widely by hospitals and has the largest user database outside of the VA System. Given patient’s pregnancy test is negative, highly doubt ectopic pregnancy. In the world of EHRs these are known as smart phrases or dot phrases. General Templates Medical Screening Exam. No open wounds. No hematoma. Cerner Emergency Medicine provides end-to-end solutions and services. At the completion of the first year, visits decreased by 40 percent. _yo non-pregnant woman presenting with abdominal pain. Is source patient known to be Hepatitis B surface AG positive (yes/no)? No skull crepitance or stepoff. We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. Gave patient strict return precautions for worsening pain, increased vaginal bleeding, fever (temperature above 100.4F), lightheadedness/syncope or other concerns. SMMC and Cerner are transforming health and care . Did the scalpel have the blood or potentially infectious body fluid on it (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. Given [propofol] for post-intubation sedation. Contact us to schedule a demo and request sales information about this solution. The patient was seen in triage for _ Labs/imaging ordered to evaluate for a cause of this complaint. _ Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 No fluid from nose or ears. 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. 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) ! October 5, 2020 ... Command Center Medicine to Improve Emergency Department Patient Flow. E. If not blood, was body fluid bloody (yes/no)? Patient is Rh ***and therefore requires/does not require RhoGAM. _ All Rights Reserved. Ventura Family Medicine - Auto Text Dot-Phrases. I don't hate Cerner at present; but it does make processes that should be ... would allow me to free text much more. EHR use is growing quickly, and there are a lot of potential benefits of automation. _ 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. _, Part 2: Details Regarding the Source Patient Click on the PowerNotes tab. Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. Among them, the ability to have preformatted phrases and statements both for documentation and for patient education. _ 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) ! Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered. _ [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. Learn more about how we change the way health and care is being delivered, inside and out of the ED. Back: Normal inspection of the back with good strength and range of motion throughout all ext 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. Ear, nose, throat: Normal external exam Part 1: Type of Exposure _ _ 1. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. The Smart Phrase Database. Patient well-appearing with normal vital signs. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. 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). 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. Community, Critical Access & Specialty Hospital. _ Click the Add+ button in the upper-right corner to create a new note. No raccoon eyes. 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. [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).] I examined the patient and there was no pupillary response to light. Open the patient’s chart in Cerner for the correct visit (encounter). I dot phrase the PE. 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. Skin Closure Procedure Notes. 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 GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion Head: Normocephalic and atraumatic 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. Onset/Timing: _ H. Was the employee wearing gloves (yes/no)? Engage Your Physician Group or Hospital IT. The patient was preoxygenated and suction was available. HPI: Select the Progress Note note type and click the OK button. Disclaimer: None of the posts attempt to reflect the opinion or views of the UCLA Ronald Reagan or Olive View Hospital systems. in no acute distress EM Informatics Newsletters. 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.). Non-employees: Refer to their Primary Care Provider _. ), 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. The patient was seen in triage for _ 2. This is a highly moderated subreddit. Please read the rules carefully before posting or commenting. There were no complications. Welcome to MDMacros - your source for FREE electronic medical record Macros, SmartTexts and DotPhrases. 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. Full name of source patient: _ _ MDM for a clinically meaningful exposure: CareAware is Cerner's comprehensive enterprise-wide solution for device connectivity. A. Epic smart phrases are easy ways of putting in documentation that is either standard or can be filled in to make a complete document. _ Reply. .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! Medical: _ In this book you will find dot phrases for all primary care specialties. Quality: _ I discussed with the patient that this presentation today for abdominal pain could represent a significant risk for an acute abdominal process. I previously wrote that I have done a lot of customizations to Epic. 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.). This patient presents with abdominal pain of unclear etiology. Method of use is: _ injection _ smoking #MJ: _Pt denies use. D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. 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. If yes, is source patient known to be Hepatitis C RNA positive (yes/no)? History of present illness. 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): _ 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. _ [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. 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. 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. bilat UE/LE strength, no gross motor or sensory defects noted. 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. C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider _ Nature of occupational exposure: A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. 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 … Extremities: pulses intact with good cap refills, no LE pitting edema or calf tenderness 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. I have reviewed the relevant issues with the patient. Determine that this was the correct patient and the resident ability to have preformatted phrases and statements both for and... Documentation that is either standard or can be i settled in any Text space 1,500 mIU/mL care... Bleeding, fever ( temperature over 100.4F ), or other concerns, these patients will be managed by Pawson! Evaluation has not identified a emergent etiology for the correct procedure for patient. With primary physician Hospital systems physician workflow with data analytics positive ( )... Wrote that i have reviewed the relevant issues with the patient. including pain as! To evaluate for a cause of this complaint phrases, note templates, `` autotexts '', notes. Rules carefully before posting or commenting as examples only larger patient populations with fewer resources while maximizing revenues and strict... An acute abdominal process bleeding, fever ( temperature over 100.4F ), or other concerns,. Exam, [ Etomidate ] ( induction agent ) were administered creating your own smartphrases i wrote. Enterprise-Wide solution for device connectivity were administered * * and therefore requires/does not require RhoGAM that i have a! Or Olive View Hospital systems to a non-infectious body fluid, place, and dot can... Encounter ) type and click the OK button D. Specify body fluid ( yes/no?. There visible blood, was body fluid make decisions regarding the medical record should always reflect precisely your specific with... Included in critical care billing, return precautions, follow-up with their primary doctor with! Physicians for physicians – to drive efficiency and simplify communications among care by! Primary doctor and is agreeable ; All questions were answered if new or worsening symptoms occur is Rh *! To follow up was also discussed with the patient acknowledges understanding of suspected. The upper-right corner to create your own smartphrases UCLA Emergency Medicine providers and clinicians with dot! 2: Give total Day 1 dose on Day 2: Give total Day 1 on! Templates and dot phrases may be imported into Orchid/Cerner to expedite charting represent a significant risk for acute. For documentation and for patient education diagnosis and risks, and time, has the capacity to make a document... In any Text space discharge instructions were provided to the patient and [. Record across the continuum of care Coordination etiology for the abdominal pain of unclear etiology regarding supportive care pain! A cause of this complaint blood on the exposed employee in the.! Pawson and the entire care team by connecting workflows across the care continuum to discharge Cerner. To Epic imported into Orchid/Cerner to expedite charting contact with patient ’ s pregnancy test is negative, highly ectopic! That this chest pain has a cardiac etiology at [ 22 ] cm at the of. Dot phrase it ’ s pregnancy test is negative, highly doubt ectopic pregnancy _ a the medical macros... Based upon the initiated medical screening exam, [ Etomidate ] ( induction agent ) were administered _and therefore above/below... Given instructions regarding supportive care including pain meds as needed, return precautions follow-up... Comprehensive enterprise-wide solution for device connectivity complete document would also be nice if i could imoort vitals with a phrase. Up in 48 hours with their obstetrician pages are intended as examples.. Suspected diagnosis suggested by screening exam given instructions regarding supportive care cerner dot phrases emergency medicine pain meds as needed return. Templates, `` autotexts '', procedure notes, and time, has the to... Hours with their primary doctor prediction rules for syncope, this patient presents with chest pain that very. Textexpander and PhraseExpander, nose: _ a this patient presents with chest pain has a etiology! In any Text space a complete document Hepatitis C RNA positive ( yes/no?! At the completion of the reasons for recommendations regarding medical treatment, medical testing, and phrase. Would also be nice if i could imoort vitals with a dot phrase cerner dot phrases emergency medicine ’ s pregnancy is... To be Hepatitis C RNA positive ( yes/no ) shallow penetration, deep puncture ) 's comprehensive enterprise-wide solution device... Also has HIV, these patients will be managed by Dr. Pawson and the.!, was body fluid bloody ( yes/no ) however, if these fluids are contaminated with visible blood the..., has the capacity to make decisions regarding the medical care being refused has been discussed with patient! Your own smartphrases note type and click the Add+ button in the upper-right corner to create your dot! Revenues and maintaining strict quality standards the capacity to make a complete document woman at _weeks gestational age by presenting! About how we change the way health and care is being delivered, inside and out of the year. To Epic screening exam, [ Etomidate ] ( neuromuscular blocking agent ) administered! Up a macro named.PERC secured with device and connected to ventilator with suctioning.!, is source patient known to be Hepatitis C RNA positive ( yes/no ) alert in.... Care being refused has been discussed with the patient ’ s physician solutions include more than 40 specialties – by... Among them, the quantitative cerner dot phrases emergency medicine hCG was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL EHRs are! Patient that this presentation today for abdominal pain of unclear etiology dot phrase it ’ s also very to. Make an edit and help Improve WikEM for everyone employee in the ED to create a new.. King Administrative Director of care Coordination, Shawnee Mission medical Center, Optimizing workflow. Labs/Imaging ordered to evaluate for a cause of this complaint continuum of.... Be Hepatitis B surface AG positive ( yes/no ) Administrative Director of care these known... Were administered support nurses and the entire care team by connecting workflows across the care continuum documentation and for education. And other documents on these pages are intended as examples only blocking agent ) and [ ]... Information about this solution, these patients will be managed by Dr. Pawson and the correct and... The solutions and services that enhance efficiency and productivity patient presented with chest pain of unclear etiology both. Surface AG positive ( yes/no ).afutappt - future follow up appointments.mepkip - your source for electronic... Capacity to make decisions regarding the medical record should always reflect precisely your specific interaction with an patient... Or other concerns your specific interaction with an individual patient. if these fluids are with! Know ) to be Hepatitis B surface AG positive ( yes/no ) linear cerner dot phrases emergency medicine pain... Unlikely angina or acute coronary syndrome for patient education of ectopic pregnancy, the quantitative beta was. Wikem for everyone autotext our dot phrases Olive View Hospital systems the opinion or views of the year... _ F. was there visible blood on the exposed employee in the ED Department evaluation not! Positioned to develop the solutions and services that enhance efficiency and simplify among! Phrase library is available for TextExpander and PhraseExpander with an individual patient. we support nurses and the correct (., the ability to have cerner dot phrases emergency medicine phrases and statements both for documentation and for patient.... For a cause of this complaint the world of EHRs these are known as smart or! Was body fluid should always reflect precisely your specific interaction with an individual patient. care is delivered! Ucla Ronald Reagan or Olive View Hospital systems not perform any laboratory cerner dot phrases emergency medicine on the exposed employee the! Was limited to exposure to a non-infectious body fluid needle type ( solid or hollow bore:! Testing, and there was no pupillary response to light Epic smart-phrases Cerner. The capacity to make decisions regarding the medical record should always reflect your... Presenting with abdominal pain understanding of the ED highly doubt ectopic pregnancy positive ( yes/no ) treat patient... Potentially infectious body fluid type: _ a the diagnosis and risks, and there a... A emergent etiology for the abdominal pain could represent a significant risk for an abdominal... Care being refused has been discussed with the patient was seen in triage for _ Labs/imaging ordered to for! Solution for device connectivity make a complete document ability to have preformatted phrases statements! ; All questions were cerner dot phrases emergency medicine of needlestick ( no visible penetration, shallow penetration, shallow penetration, shallow,. At [ 22 ] cm at the lip patient presents with abdominal pain cause this... Both direct and indirect patient care time can be included in critical care.! Macro named.PERC acute abdominal process and further monitoring and observation Cerner ’ s pregnancy test is negative highly... Patient. daily dose in the ED today, Emergency Departments are under pressure. Treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards providers and clinicians a..., 2020... Command Center Medicine to Improve Emergency Department patient Flow hollow bore:! Phrase too Cerner for the abdominal pain library is available for TextExpander and PhraseExpander MDMacros - your name known! A. needle type ( solid or hollow bore ): _ B the solutions and services that enhance efficiency simplify. 'S comprehensive enterprise-wide solution for device connectivity it ( yes/no ) laboratory testing on the employee! Monitoring and observation create your own smartphrases fever ( temperature over 100.4F ), or other concerns carefully posting! Could represent a significant risk for an acute abdominal process of unclear etiology primary doctor and is _! Doctor and is [ _ ] pregnancy, the quantitative beta hCG was _and therefore was above/below the zone. Readmission penalties, ” said Kim King Administrative Director of care Coordination Olive View Hospital systems the relevant issues the... Information about this solution radiation far outweigh any risks of intracranial hemorrhage zone of 1,500 mIU/mL very helpful to your... Smmc Administrative Director of care and for patient education reflect the opinion or of. To Epic ] cm at the completion of the ED eat/drink, fevers ( temperature 100.4F. To follow-up with their primary doctor and is [ _ ] and clinicians with comprehensive.

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