CC: CP - Putting it all together
This is where I suggest you take my template below and make it your own. We all do things differently (and have different EMR systems). Below is a cut-and-paste from a quick phrase I have in my hospital’s EMR. We use EPIC so some of you might recognize the @phrases@ as places where the system will auto-populate the document. Many systems do this, which is great for speeding up documentation, but how many of us actually read every word that is imported into the history portion of the chart, and how accurate is that information?
I will tell you who does read every word of an ER note, a lawyer looking for a breach in the standard of care! By auto-populating my note, I am essentially saying that I have read or am aware of information pulled from the chart and put on my note. That is why you will see many *** below sections such as @PMH@ which I really should review for specific diseases and risk factors.
There are other parts of my note that are specific phrases that I use, which you should consider changing to your own style of documentation, and other parts of the note below that are specific to my software and workflow. DON’T COPY & PASTE this as a defense against getting sued or as a catch all for every potential diagnosis. DO think about your own practice and workflow and design a template that is uniquely yours and can be easily adapted to reflect what you actually did on every patient.
EMERGENCY DEPARTMENT ENCOUNTER
CHIEF COMPLAINT
@CC@
HPI
@NAME@ is a @AGE@ @SEX@ who presents with *** chest pain.
PAST MEDICAL HISTORY
@PMH@
Reviewed for risk factors of prior CAD or MI, HTN, DM, PE or DVT, or other vasculopathy.
SURGICAL HISTORY
@PSH@
*** recent surgeries or immobilizations.
CURRENT MEDICATIONS
@LHEDMEDS@
*** current oral contraceptive pill.
ALLERGIES
@ALLERGY@
FAMILY HISTORY
@FAMHX@
*** history of premature heart disease or MI under the age of 55.
SOCIAL HISTORY
@SOC@
Reviewed for current or recent smoking, cocaine use, or IVDU.
REVIEW OF SYSTEMS
See HPI
PHYSICAL EXAM
VITAL SIGNS: @EDTRIAGEVITALS@
GENERAL: ***
Head: Normocephalic, atraumatic.
Neck: Supple. Jugular veins ***.
Cardiovascular: *** heart rate, *** rhythm. *** systolic or diastolic murmurs or extra sounds.
Respiratory: *** respiratory distress. *** wheezing. *** rhonchi. *** rales.
Chest: No rash or tenderness.
Abdomen: Soft, no tenderness, no masses, no pulsatile masses.
Integument: *** diaphoresis.
Extremities: *** radial pulse. *** upper extremity edema or cyanosis. *** lower extremity edema.
Neurologic: Alert and oriented with no signs of AMS, lethargy, or confusion.
Psych: *** anxiety. Appropriate mood and affect.
EKG
*** rhythm, *** rate. PR interval *** ms, QRS *** ms, and QTc *** ms. *** ST-segment elevation or hyper-acute T waves. *** new ST depression. There were *** T wave inversions compared to prior EKG.
Posterior MI considered with no ST depression in V1-V3. ECG examined for Wellen syndrome - no deep precordial T wave inversions or biphasic T waves in V2-3 and De Winter T waves - no upsloping ST depression with peaked T waves in precordial leads. Sgarbossa criteria considered if LBBB/paced ECG. A large S wave in lead I, a Q wave in lead III, and an inverted T wave in lead III seen in acute right heart strain *** seen. Electrical alternans suspicious for large pericardial effusion *** present.
Independently viewed by attending MD and read by me at the bedside.
RADIOLOGY
***
CXR showed *** by my read. See the radiologist read above (if available).
PROCEDURES
Echocardiogram was done and interpreted at the bedside by me showed ***.
LABS
***
Reviewed for profound anemia. *** kidney function. No significant electrolyte abnormalities. Troponin ***. D-dimer considered ***.
ED COURSE:
Pertinent Labs & Imaging studies reviewed. (See chart for details)
MEDICAL DECISION MAKING
Pertinent Labs & Imaging studies reviewed. (See chart for details)
@NAME@ is a @AGE@ @SEX@ with *** risk factors for ACS. EKG was reviewed. Troponin testing ***. The HEART score was applied according to the department’s accelerated diagnostic protocol.
Clinically significant PE was also considered with the patient having *** risk factors. Well's criteria was used to risk stratify with the patient *** for PE. The PERC criteria was *** applied. Further work-up *** indicated.
The patient is *** at high risk for aortic dissection with presentation and examination *** consistent with this diagnosis.
Pneumothorax *** detected on exam and *** seen on CXR.
Infectious etiology considered. The patient has *** fever, chills, cough, or hemoptysis. There is no history of recent IVDU and no signs or septic emboli on examination. The patient is not at risk for aspiration pneumonia.
Gastritis, GERD, and pancreatitis were considered with no risk factors or historical clues to support this.
Pain is *** increased with lying or relieved with sitting up to suggest pericarditis with *** pericardial effusion seen on bedside ultrasound.
@LHEDCI@
REFRESH BEFORE SIGNING***
