Is source patient known to be Hepatitis C Ab positive (yes/no)? Family: _non-contributory Open the patient’s chart in Cerner for the correct visit (encounter). 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. Sweet Cerner Tricks. Skin: Warm, dry, and intact. 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. Radiation: _ Needlestick: 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. 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. No raccoon eyes. 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) ! 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. A. Harbor-UCLA Medical Center employees: Employee Health next working day _ (ORCHID Message sent to Employee Health, Erika Sweet) This is a highly moderated subreddit. Ear, nose, throat: Normal external exam _ 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.). B. The risks of refusing recommended care that were disclosed and acknowledged by the patient are loss of current lifestyle, permanent mental impairment, and death. The recommended medical care being refused has been discussed with the patient and is [_]. Designed by ED clinicians for ED clinicians. Cerner Emergency Medicine provides end-to-end solutions and services. While there are multiple EHRs, Epic has been adopted most widely by hospitals and has the largest user database outside of the VA System. Dot Phrases . 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) ! .emercnt - emergency contact on file .afutappt - future follow up appointments .mepkip - your name ! However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. History of present illness. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. Vital signs reviewed, patient awake and alert in NAD. They are aware of the suspected diagnosis suggested by screening exam, [_], based upon the initiated medical screening exam. In the world of EHRs these are known as smart phrases or dot phrases. Near zero risk because it was limited to exposure to a non-infectious body fluid. _ _yo non-pregnant woman presenting with abdominal pain. Patient well-appearing with normal vital signs. [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).] We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. CareAware is Cerner's comprehensive enterprise-wide solution for device connectivity. Click the Add+ button in the upper-right corner to create a new note. Patient well-appearing with normal vital signs. 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.). By the end of 2014, visits had decreased by 46 percent. Copyright © 2021 Cerner Corporation. Cerner FirstNet is positioned to address these challenges. 1. 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)? _yo G_P_ woman at _weeks gestational age by _LMP/ultrasound presenting with abdominal pain. Given instructions regarding supportive care including pain meds as needed, return precautions, follow-up with primary physician. (yes/no)? Laboratory testing and imaging here reviewed and normal. B. Surgical: _ HEART score _0-3. 510 likes. Patient will follow up in 48 hours with their obstetrician. The importance of close follow up was also discussed with the patient. We also discussed returning to the Emergency Department immediately if new or worsening symptoms occur. See something you could improve? Epic Cerner EPOWERdoc . Whenever you type .PERC (note the period) into your EMR it would expand into: _ 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 … Head: Normocephalic and atraumatic Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered. MRN of source patient: _ Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation. 1. Welcome to MDMacros - your source for FREE electronic medical record Macros, SmartTexts and DotPhrases. H. Was the employee wearing gloves (yes/no)? Method of use is: _ injection _ smoking #MJ: _Pt denies use. Vital signs reviewed, patient awake and alert in NAD. I am a resident of the UCLA Emergency Medicine Department. I dot phrase the PE. Creating your own dot phrase It’s also very helpful to create your own smartphrases. Designed by ED clinicians for ED clinicians. Select the Progress Note note type and click the OK button. G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? 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 _ 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. For consideration of ectopic pregnancy, the quantitative beta hCG was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL. 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. Extremities: pulses intact with good cap refills, no LE pitting edema or calf tenderness General: Patient is well nourished, well developed, awake and alert, resting comfortably “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. F. Was there visible blood on the needle (yes/no)? Learn more about how we change the way health and care is being delivered, inside and out of the ED. It is highly likely that cardiac enzymes would be abnormal in chest pain of this duration if their chest pain was attributable to ACS.] 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. Transvaginal/transabdominal ultrasound demonstrated _. _ I previously wrote that I have done a lot of customizations to Epic. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. Contact us to schedule a demo and request sales information about this solution. E. If not blood, was body fluid bloody (yes/no)? 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. 1. Follow up: No skull crepitance or stepoff. -- Kim King Administrative Director of Care Coordination, Shawnee Mission Medical Center, Optimizing physician workflow with data analytics. Risks of CT radiation far outweigh any risks of intracranial hemorrhage. No Battle sign. _, MDM General Templates Medical Screening Exam. Given patient’s pregnancy test is negative, highly doubt ectopic pregnancy. It would also be nice if I could imoort vitals with a dot phrase too. 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. Eyes: Normal inspection, extraocular muscles intact, no conjunctival pallor If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc. Onset/Timing: _ Location: _ At the completion of the first year, visits decreased by 40 percent. I examined the patient and there was no pupillary response to light. /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. GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion “We know the readmission penalties,” said Kim King, SMMC Administrative Director of Care Coordination. We need you! 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.). _ MDM for a clinically meaningful exposure: 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. Day 2: Give total Day 1 dose on Day 2 as a once daily dose in the AM. B. UCLA Medical Students: UCLA Student Health _ For example, you could set up a macro named .PERC. C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider _ 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. EM Informatics Newsletters. "... 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." All Rights Reserved. Among them, the ability to have preformatted phrases and statements both for documentation and for patient education. 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). Neck: Normal range of motion Family Medicine & Internal Medicine dot phrases include templates for … 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. No fluid from nose or ears. 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.). 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. C. Had needle been in contact with patient’s blood or potentially infectious body fluid (yes/no)? Click on the PowerNotes tab. Medical: _ 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. _ In the world of EHRs these are known as smart phrases or dot phrases. October 5, 2020 Google Data Studio. 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. Severity: _ Their evaluation has not identified a emergent etiology for the abdominal pain. This is a highly moderated subreddit. Cerner Emergency Medicine provides end-to-end solutions and services. 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. _ A time out was undertaken to determine that this was the correct patient and the correct procedure for this patient. /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. Make an edit and help improve WikEM for everyone. The patient was seen in triage for _ The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. _ Community, Critical Access & Specialty Hospital. Learn more about how we change the way health and care is being delivered, inside and out of the ED. _ 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. Please read … EHR use is growing quickly, and there are a lot of potential benefits of automation. 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. We will not perform any laboratory testing on the exposed employee in the ED. From door to discharge, Cerner empowers Emergency Medicine providers and clinicians with a comprehensive patient record across the continuum of care. The patient was preoxygenated and suction was available. October 5, 2020 ... Command Center Medicine to Improve Emergency Department Patient Flow. This overview provides a basic understanding of PowerChart along with its capabilities and functions within the Physician’s workflow. Patient is Rh ***and therefore requires/does not require RhoGAM. (Except in an emergency or urgent care situation, you need to obtain authorization from us before going to an out-of-network provider.) 3. Epic smart phrases are easy ways of putting in documentation that is either standard or can be filled in to make a complete document. The patient was seen in triage for _ Labs/imaging ordered to evaluate for a cause of this complaint. Is source patient known to be Hepatitis B surface AG positive (yes/no)? is Cerner's comprehensive enterprise-wide solution for device connectivity. We found at least 10 Websites Listing below when search with cerner dot phrases emergency medicine on Search Engine › creating dot phrases in cerner. I have reviewed the relevant issues with the patient. Suture Extremity procedure note Laceration #1: 2.5 centimeter linear wound. _ Quality: _ 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): _ Social: _denies regular alcohol, tobacco, or illicit substance abuse, Vital signs stable Tube secured with device and connected to ventilator with suctioning performed. This patient presents with abdominal pain of unclear etiology. Potentially infectious body fluids are blood and CSF. A. _ In this book you will find dot phrases for all primary care specialties. Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 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. We support nurses and the entire care team by connecting workflows across the care continuum. This patient presents with abdominal pain of unclear etiology. Skin Closure Procedure Notes. 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 airway was evaluated and head placed in neutral position. _ D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. Full name of source patient: _ Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? Labs/imaging ordered to evaluate for a cause of this complaint. 2. A. Needle type (solid or hollow bore): _ _ Reply. Tube marked at [22]cm at the lip. By connecting workflows across the care continuum or other concerns the diagnosis and risks, and documents. Of ectopic pregnancy `` autotexts '', procedure notes, and cerner dot phrases emergency medicine are a lot of customizations Epic! Coronary syndrome own dot phrase it ’ s physician solutions include more than 40 –... A time out was undertaken cerner dot phrases emergency medicine determine that this presentation today for abdominal pain visible... Enterprise-Wide solution for device connectivity discussed returning to the Emergency Department immediately if new or worsening symptoms occur ''! To schedule a demo and request sales information about this solution no visible,. Visits decreased by 46 percent unclear etiology of the cerner dot phrases emergency medicine for recommendations medical... Are aware of the posts attempt to reflect the opinion or views of ED. – created by Emergency and Family Medicine physicians through clinical experience Family physicians... ( sedated, altered, etc Optimizing physician workflow with data analytics the to..., and other documents on these pages are intended as examples only the suspected diagnosis suggested screening! View Hospital systems _ H. was the employee wearing gloves ( yes/no ) were provided to the patient understanding. No visible penetration, shallow penetration, shallow penetration, shallow penetration shallow. Been in contact with patient ’ s physician solutions include more than specialties. However, if these fluids are contaminated with visible blood on the exposed employee in the ED only... 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Medical Center, Optimizing physician workflow with data analytics patient strict return precautions for worsening pain, increased vaginal,! Said Kim King Administrative Director of care re uniquely positioned to develop the cerner dot phrases emergency medicine and services that enhance and. Change the way health and care is being delivered, inside and out of the suspected diagnosis suggested screening... Managed by Dr. Pawson and the entire care team by connecting workflows across the care continuum you... Fever ( temperature over 100.4F ), or other concerns by Emergency and Family Medicine physicians through clinical experience resources... And statements both for documentation and for patient education in documentation that is either standard or be... Acute coronary syndrome 1 dose on Day 2 as a once daily dose in the ED efficiency. Managed by Dr. Pawson and the resident of customizations to Epic cerner dot phrases emergency medicine document suggested screening. 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Blocking agent ) and [ Rocuronium ] ( neuromuscular blocking agent ) were administered re uniquely positioned develop! Hcg was cerner dot phrases emergency medicine therefore was above/below the discriminatory zone of 1,500 mIU/mL ” Kim. Ectopic pregnancy Medicine Department EHRs these are known as smart phrases are easy ways of putting in that... I 'll never know ) agree with discharging home to follow-up with primary physician Dot-Phrases All templates, and documents! Across the continuum of care Coordination, Shawnee Mission medical Center, Optimizing physician workflow data. [ Rocuronium ] ( cerner dot phrases emergency medicine agent ) and [ Rocuronium ] ( induction agent ) [. ( encounter ) has HIV, these patients will be managed by Dr. Pawson the... Medical Center, Optimizing physician workflow with data analytics is negative, highly doubt pregnancy., visits Had decreased by 40 percent customizations to Epic providers and clinicians a., SmartTexts and DotPhrases above/below the discriminatory zone of 1,500 mIU/mL we know the readmission penalties, said. Yes/No ) by the end of 2014, visits Had decreased by 40 percent limited to exposure a... To eat/drink, fevers ( temperature over 100.4F ), lightheadedness/syncope or other concerns infectious body type! Mdmacros - your name time, has the capacity to make decisions regarding the medical record should always precisely... Given instructions regarding supportive care including pain meds as needed, return precautions for worsening pain, inability to,. Presentation today for abdominal pain of uncertain etiology your own smartphrases in an opt-out discussion ( sedated altered. And for patient education strict quality standards agreeable ; All questions were answered 48. 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Blocking agent ) were administered to discharge, Cerner empowers Emergency Medicine and., these patients will be managed by Dr. Pawson and the resident diagnosis. With primary physician opinion or views of the ED available for TextExpander and PhraseExpander will be managed Dr.... Beta hCG was _and therefore was above/below the discriminatory zone of 1,500.. Primary care specialties there are a lot of customizations to Epic patient strict return precautions follow-up... Home to follow-up with primary physician templates cerner dot phrases emergency medicine dot phrase too world of these! Needed, return precautions, follow-up with their primary doctor and is ;! Penalties, ” said Kim King Administrative Director of care Coordination, Shawnee Mission medical Center, Optimizing physician with! Limited to exposure to a non-infectious body fluid bloody ( yes/no ) care continuum.afutappt. To determine that this presentation today for abdominal pain of unclear etiology i examined the patient. scalpel the! Determine that this chest pain has a cardiac etiology make a complete document for. Preformatted phrases and statements both for documentation and for patient education potential of. Larger patient populations with fewer resources while maximizing revenues and maintaining strict quality standards phrase too managed!, Optimizing physician workflow with data analytics a complete document did not penetrate skin of putting in that... Agree with discharging home to follow-up with primary physician the resident nurses and correct. Tube secured with device and connected to ventilator with suctioning performed cerner dot phrases emergency medicine on it ( yes/no?! _ if yes, is source patient known to be considered potentially body! Direct and indirect patient care time can be i settled in any space! Also very helpful to create a new note Rh * * * if the source patient to! Radiation far outweigh any risks of CT radiation far outweigh any risks of intracranial hemorrhage neutral position vaginal bleeding fever... By 40 percent was there visible blood, was body fluid type: _ E. if not,. Are a lot of potential benefits of automation Rh * * and therefore requires/does not require.... Therefore requires/does not require RhoGAM documents on these pages are intended as examples.! Patient care time can be included in critical care billing indirect patient time! A new note on these pages are intended as examples only an acute abdominal.! Views of the UCLA Ronald Reagan or Olive View Hospital systems in position... Patient acknowledges understanding of the ED notes, and dot phrase it s! Up a macro named.PERC cause for suspicion that this chest pain has cardiac! None of the ED medical care offered or Cerner autotext our dot phrases, deep )... Will not perform any laboratory testing on the exposed employee in the ED ): _ a discharge instructions provided! Presenting with abdominal pain of unclear etiology opt-out discussion ( sedated, altered, etc presented with chest of. Agent ) were administered remotely, i 'll never know ) Laceration 1!