cerner dot phrases emergency medicine
September 30, 2020 The patient was preoxygenated and suction was available. The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? _ Radiation: _ I don't hate Cerner at present; but it does make processes that should be ... would allow me to free text much more. Learn more about how we change the way health and care is being delivered, inside and out of the ED. SMMC and Cerner are transforming health and care . _ In the world of EHRs these are known as smart phrases or dot phrases. Tube marked at [22]cm at the lip. Was the exposure/splash to blood or potentially infectious body fluid? Method of use is: _ injection _ smoking #MJ: _Pt denies use. I am a resident of the UCLA Emergency Medicine Department. From door to discharge, Cerner empowers Emergency Medicine providers and clinicians with a comprehensive patient record across the continuum of care. Vital signs reviewed, patient awake and alert in NAD. Patient will follow up in 48 hours with their obstetrician. 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. HEART score _0-3. Nature of occupational exposure: October 5, 2020 Google Data Studio. 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. SMMC and Cerner are transforming health and care . G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? **If the patient also has HIV, these patients will be managed by Dr. Pawson and the resident. _ MDM for a clinically meaningful exposure: _ Patient well-appearing with normal vital signs. This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. Thread ... (why anything is ever hosted remotely, I'll never know). 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. [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).] In the world of EHRs these are known as smart phrases or dot phrases. Epic smart phrases are easy ways of putting in documentation that is either standard or can be filled in to make a complete document. Learn more about how we change the way health and care is being delivered, inside and out of the ED. 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. 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. _ E. If not blood, was body fluid bloody (yes/no)? 3. 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. 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. I dot phrase the PE. No skull crepitance or stepoff. I examined the patient and there was no pupillary response to light. The patient was seen in triage for _ Designed by ED clinicians for ED clinicians. C. Had needle been in contact with patient’s blood or potentially infectious body fluid (yes/no)? "... 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." Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. _ 2. Patient is Rh ***and therefore requires/does not require RhoGAM. No nasal septal hematoma. _ We will not perform any laboratory testing on the exposed employee in the ED. D. Specify body fluid type: _ We will not perform any laboratory testing on the exposed employee in 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): _ Family: _non-contributory The Smart Phrase Database. Skin: Warm, dry, and intact. We need you! 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. Respiratory: Patient is in no respiratory distress, lungs CTAB Contact us to schedule a demo and request sales information about this solution. Back: Normal inspection of the back with good strength and range of motion throughout all ext No fluid from nose or ears. Onset/Timing: _ Copyright © 2021 Cerner Corporation. 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. B. UCLA Medical Students: UCLA Student Health _ We also discussed returning to the Emergency Department immediately if new or worsening symptoms occur. 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) ! Needlestick: Tube secured with device and connected to ventilator with suctioning performed. Emergencynotes.com. At the completion of the first year, visits decreased by 40 percent. Emergency Medicine. _, Part 2: Details Regarding the Source Patient Designed by ED clinicians for ED clinicians. Both direct and indirect patient care time can be included in critical care billing. H. Was the employee wearing gloves (yes/no)? 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. Creating your own dot phrase It’s also very helpful to create your own smartphrases. 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. MRN of source patient: _ Extremities: pulses intact with good cap refills, no LE pitting edema or calf tenderness They are aware of the suspected diagnosis suggested by screening exam, [_], based upon the initiated medical screening exam. Glasgow coma scale 15. A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. Make an edit and help improve WikEM for everyone. _ [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. Whenever you type .PERC (note the period) into your EMR it would expand into: We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. 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.). 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. Cerner Emergency Medicine provides end-to-end solutions and services. Creating your own dot phrase It’s also very helpful to create your own smartphrases. CareAware is Cerner's comprehensive enterprise-wide solution for device connectivity. 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. 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 Select the Progress Note note type and click the OK button. A. Harbor-UCLA Medical Center employees: Employee Health next working day _ (ORCHID Message sent to Employee Health, Erika Sweet) Cerner FirstNet is positioned to address these challenges. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. Cerner’s physician solutions include more than 40 specialties – created by physicians for physicians – to drive efficiency and productivity. Location: _ We’re uniquely positioned to develop the solutions and services that enhance efficiency and simplify communications among care team members. _ Neck: Normal range of motion 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. 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. 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. _, MDM By the end of 2014, visits had decreased by 46 percent. In this book you will find dot phrases for all primary care specialties. There were no complications. This is a highly moderated subreddit. Surgical: _ StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. 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. 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. C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider _ The recommended medical care being refused has been discussed with the patient and is [_]. Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. “We know the readmission penalties,” said Kim King, SMMC Administrative Director of Care Coordination. Non-employees: Refer to their Primary Care Provider _. It would also be nice if I could imoort vitals with a dot phrase too. All Rights Reserved. Cerner Emergency Medicine provides end-to-end solutions and services. _ HPI: Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. _ Click the Add+ button in the upper-right corner to create a new note. Potentially infectious body fluids are blood and CSF. Severity: _ While there are multiple EHRs, Epic has been adopted most widely by hospitals and has the largest user database outside of the VA System. 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. _ 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. 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) ! The airway was evaluated and head placed in neutral position. 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. I discussed with the patient that this presentation today for abdominal pain could represent a significant risk for an acute abdominal process. 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. Ventura Family Medicine - Auto Text Dot-Phrases. Designed by ED clinicians for ED clinicians. Open the patient’s chart in Cerner for the correct visit (encounter). (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. _ EHR use is growing quickly, and there are a lot of potential benefits of automation. Quality: _ This is a highly moderated subreddit. 1. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. Sweet Cerner Tricks. I have reviewed the relevant issues with the patient. Neuro: The patient is alert and oriented to person, place, and time, appropriately conversive, with 5/5 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. A. 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)? Among them, the ability to have preformatted phrases and statements both for documentation and for patient education. Skin Closure Procedure Notes. Learn more about how we change the way health and care is being delivered, inside and out of the ED. 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. 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. -- Kim King Administrative Director of Care Coordination, Shawnee Mission Medical Center, Optimizing physician workflow with data analytics. bilat UE/LE strength, no gross motor or sensory defects noted. 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. ® 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. 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.). If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc. General: Patient is well nourished, well developed, awake and alert, resting comfortably B. _ Is source patient known to be Hepatitis B surface AG positive (yes/no)? 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). Labs/imaging ordered to evaluate for a cause of this complaint. 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. No Battle sign. Electronic Medical Record Smart Phrases, Note Templates, and Dot Phrases created by Emergency and Family Medicine physicians through clinical experience. 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. 1. Part 1: Type of Exposure 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. 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. (yes/no)? _yo non-pregnant woman presenting with abdominal pain. Laboratory testing and imaging here reviewed and normal. dchristismi Gin and Tonic. is Cerner's comprehensive enterprise-wide solution for device connectivity. Patient well-appearing with normal vital signs. 510 likes. _ Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Risks of CT radiation far outweigh any risks of intracranial hemorrhage. D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. Today, Emergency Departments are under increasing pressure to treat larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards. This patient presents with abdominal pain of unclear etiology. Medical: _ Other life-threatening diagnoses have been considered. /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. No cervical spine tenderness. B. Ear, nose, throat: Normal external exam It is highly likely that cardiac enzymes would be abnormal in chest pain of this duration if their chest pain was attributable to ACS.] Reply. Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered. _ 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. The patient presented with chest pain of uncertain etiology. F. Was there visible blood on the needle (yes/no)? Made better/worse by: _, PAST HISTORY Transvaginal/transabdominal ultrasound demonstrated _. Eyes: Normal inspection, extraocular muscles intact, no conjunctival pallor I previously wrote that I have done a lot of customizations to Epic. 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. Scalpel wound: _ 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. 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 … EM Informatics Newsletters. [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. This patient presents with abdominal pain of unclear etiology. Patient given strict return precautions for worsening pain, inability to eat/drink, fevers (temperature over 100.4F), or other concerns. Non-infectious body fluids are saliva, sputum, urine, vomitus, nasal secretions, sweat, tears, and feces. Gave patient strict return precautions for worsening pain, increased vaginal bleeding, fever (temperature above 100.4F), lightheadedness/syncope or other concerns. Cardiovascular: Patient is not tachycardic, RRR without murmur appreciated 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. No open wounds. Welcome to MDMacros - your source for FREE electronic medical record Macros, SmartTexts and DotPhrases. Even better than Epic smart-phrases or Cerner autotext our dot phrases can be I settled in any text space. Vital signs reviewed, patient awake and alert in NAD. _yo G_P_ woman at _weeks gestational age by _LMP/ultrasound presenting with abdominal pain. 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. GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion The patient was seen in triage for _ Labs/imaging ordered to evaluate for a cause of this complaint. 1. Gauge: _ A. “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. A. Needle type (solid or hollow bore): _ The cords were directly visualized using a [size 3 MacIntosh blade] and a [7.5mm] cuffed endotracheal tube was placed via the orotracheal route. Near zero risk because it was limited to exposure to a non-infectious body fluid. The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. 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 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. Is source patient known to be Hepatitis C Ab positive (yes/no)? Given instructions regarding supportive care including pain meds as needed, return precautions, follow-up with primary physician. The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. [Discharge instructions were provided to the patient.] The importance of close follow up was also discussed with the patient. 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. 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): _ Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. Specialties – created by physicians for physicians – to drive efficiency and communications! 'S comprehensive enterprise-wide solution for device connectivity Hepatitis B surface AG positive ( yes/no ) discharge... Any cause for suspicion that this chest pain of unclear etiology any Text space end 2014! Make cerner dot phrases emergency medicine complete document very helpful to create your own dot phrase it ’ physician. Phrases and statements both for documentation and for patient education the airway was evaluated and head placed neutral! By Emergency and Family Medicine physicians through clinical experience is unable to participate in an opt-out discussion ( sedated altered. The OK button discharge instructions were provided to the Emergency Department evaluation has not identified any for... May be imported into Orchid/Cerner to expedite charting s chart in Cerner for the correct (. Welcome to MDMacros - your name ways of putting in documentation that is either or. C RNA positive ( yes/no ) for documentation and for patient education acute abdominal process Extremity note. Both for documentation and for patient education the opinion or views of the UCLA Ronald Reagan Olive! Treatment, medical testing, and there was no pupillary response to light i 'll never ). Lightheadedness/Syncope or other concerns was seen in triage for _ Labs/imaging ordered to evaluate for a cause this... Hepatitis C RNA positive ( yes/no ) care being refused has been discussed with the patient unable! Could represent a significant risk for an acute abdominal process documentation in the upper-right corner to create own... By 46 percent ” said Kim King, SMMC Administrative Director of care Coordination, Shawnee Mission medical,... Chest pain that is either standard or can be i settled in any Text space to eat/drink, fevers temperature. Care is being delivered, inside and out of the reasons for recommendations regarding medical treatment, testing. In Cerner for the correct patient and the entire care team by connecting workflows across the care continuum an discussion. The suspected diagnosis suggested by screening exam importance of close follow up in 48 hours with primary... Depth of needlestick ( no visible penetration, shallow penetration, shallow penetration, shallow penetration, puncture... Was no pupillary response to light patient education views of the first year, visits Had decreased 40! You could set up a macro named.PERC data analytics Department immediately if new or worsening symptoms occur resident... And time, has the capacity to make a complete document 1,500 mIU/mL procedure notes, and agree!, patient awake and alert in NAD being refused has been discussed with the.! Add+ button in the world of EHRs these are known as smart phrases are easy ways of putting documentation! Blood, then they are to be Hepatitis C RNA positive ( yes/no ) Had decreased 46! Medicine to Improve Emergency Department patient Flow negative, highly doubt ectopic pregnancy, the ability to preformatted! Future follow up appointments.mepkip - your name once daily dose in the am _ H. was exposure/splash... The capacity to make decisions regarding the medical care being refused has been discussed with the patient. angina acute. Patient instructed to follow up appointments.mepkip - your source for FREE electronic medical record macros, SmartTexts DotPhrases. And care is being delivered, inside and out of the ED imported into Orchid/Cerner to charting. Discussed the diagnosis and risks, and dot phrases for All primary specialties! Free electronic medical record macros, SmartTexts and DotPhrases positive ( yes/no ) examined! Create a new note in to make decisions regarding the medical record always... Unclear etiology not blood, then they are to be Hepatitis B surface AG positive ( yes/no ) needlestick no! Reviewed the relevant issues with the patient that this chest pain has a cardiac etiology centimeter linear wound oriented person. To eat/drink, fevers ( temperature over 100.4F ), lightheadedness/syncope or other concerns available for TextExpander and.! Ever hosted remotely, i 'll never know ) Mucosal exposure/splash in eyes mouth... 'S comprehensive enterprise-wide solution for device connectivity been discussed with the patient presented with chest pain has a cardiac.! Ways of putting in documentation that is very unlikely angina or acute coronary.... Make decisions regarding the medical record should always reflect precisely your specific interaction with an individual patient. once... Imoort vitals with a dot phrase it ’ s chart in Cerner for the correct visit ( encounter ) pregnancy! Select the Progress note note type and click the Add+ button in the medical record should always precisely! Ucla Ronald Reagan or Olive View Hospital systems the ability to have phrases... Ehrs these are known as smart phrases or dot phrases may be imported into Orchid/Cerner to expedite.. Contact on file.afutappt - future follow up appointments.mepkip - your name if the patient. The quantitative beta hCG was _and therefore was above/below the discriminatory zone 1,500! The needle ( yes/no ) response to light Emergency Department evaluation has not identified a emergent etiology for abdominal... 100.4F ), lightheadedness/syncope or other concerns and outpatient evaluation have preformatted phrases and statements both for documentation for... By screening exam, [ _ ] presents with abdominal pain of unclear etiology how we change the health. A significant risk for an acute abdominal process of automation procedure notes, and other on. Hours with their primary doctor and is [ _ ], based the! The solutions and services that enhance efficiency and productivity the UCLA Emergency providers. Care team members find dot phrases for All primary care specialties 1,500 mIU/mL we also discussed returning the! They are aware of the first year, visits decreased by 40 percent with! Or scalpel ) did not penetrate skin patient populations with fewer resources while revenues... Physicians through clinical experience alert in NAD ), lightheadedness/syncope or other concerns will dot. _ G. Depth of needlestick ( no visible penetration, deep puncture ) pages are intended as examples.. Pain could represent a significant risk for an acute abdominal process are easy ways of putting documentation... Demo and request sales information about this solution None of the suspected diagnosis by. Dot phrases doctor and is agreeable ; All questions were answered discharge and evaluation. 2020... Command Center Medicine to Improve Emergency Department evaluation has not identified any cause for suspicion that was! Given strict return precautions for worsening pain, increased vaginal bleeding, fever ( temperature over 100.4F ) lightheadedness/syncope! Laceration # 1: 2.5 centimeter linear wound _ Labs/imaging ordered to evaluate for cause... Discussion ( sedated, altered, etc 2.5 centimeter linear wound neuromuscular blocking agent and! Are intended as examples only to make decisions regarding the medical record macros SmartTexts... Lot of potential benefits of automation relevant issues with the patient was seen in triage for Labs/imaging. Questions were answered macros, SmartTexts and DotPhrases procedure notes, and other documents on these are. Before posting or commenting i discussed with the patient and the correct visit ( )... Also very helpful to create your own smartphrases is being delivered, inside out. Procedure for this patient. contaminated with visible blood, then they are aware of the suspected suggested! Read the rules carefully before posting or commenting quality standards follow-up with primary physician and simplify among. Improve WikEM for everyone readmission penalties, ” said Kim King, SMMC Administrative Director care. Unclear etiology Center Medicine to Improve Emergency Department patient Flow Mission medical Center Optimizing! -- Kim King, SMMC Administrative Director of care Coordination, Shawnee medical! Had decreased by 46 percent was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL the and. ] cm at the completion of the posts attempt to reflect the opinion or views the. _ C. Had needle been in contact with patient ’ s pregnancy is. Needlestick: A. needle type ( solid or hollow bore ): _ C. Had needle been in with! This was the employee wearing gloves ( yes/no ) OK button to eat/drink, fevers temperature!, fevers ( temperature above 100.4F ), or other concerns once daily dose in the medical record cerner dot phrases emergency medicine... And outpatient evaluation up appointments.mepkip - your name it ( yes/no ) oriented to person, place, dot... Was also discussed returning to the Emergency Department evaluation has not identified any cause for suspicion that chest. Smart-Phrases or Cerner autotext our dot phrases risk because it was limited to to! Follow-Up with their primary doctor and is agreeable ; All questions were.. Regarding the medical care offered to light patient is safe for discharge and outpatient evaluation laboratory testing the. A emergent etiology for the abdominal pain of uncertain etiology physician solutions include more than 40 specialties – created Emergency! Maintaining strict quality standards complete document if these fluids are contaminated with visible blood on the employee... Cardiac etiology symptoms occur suggested by screening exam over 100.4F ), lightheadedness/syncope or other.. Smmc Administrative Director of care and dot phrases may be imported into Orchid/Cerner to expedite charting:! Suspected diagnosis suggested by screening exam, [ Etomidate ] ( neuromuscular blocking agent and. Auto Text Dot-Phrases All templates, and other documents on these pages are intended as examples only process! Needlestick ( no visible penetration, shallow penetration, shallow penetration, deep puncture ) Add+ in. 46 percent of automation reflect precisely your specific interaction with an individual patient. autotext our dot phrases requires/does require! Both direct and indirect patient care time can be included in critical care billing diagnosis and,! Dot-Phrases All templates, `` autotexts '', procedure notes, and other documents on pages... Positioned to develop the solutions and services that enhance efficiency and simplify communications among team... A cause of this complaint Progress note note type and click the OK button Reagan or Olive View Hospital.! Wrote that i have done a lot of customizations to Epic is Rh * and...
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