Harbor: Macros and Autotext
- 1 Macros
- 2 General Templates
- 3 Physical Exam
- 4 Adult Medical Decision Making
- 4.1 Discharges
- 4.1.1 AMA
- 4.1.2 General Abdominal Pain with CT
- 4.1.3 General Abdominal Pain without CT
- 4.1.4 Abdominal Pain in Females
- 4.1.5 Vaginal Bleeding
- 4.1.6 Back Pain
- 4.1.7 Low-risk Chest Pain
- 4.1.8 Chest Pain Cardiac with negative troponin (low HEART score)
- 4.1.9 Extremity
- 4.1.10 Headache
- 4.1.11 Rash
- 4.1.12 Shortness of Breath Asthma/COPD
- 4.1.13 Syncope
- 4.1.14 Occupational Exposure
- 4.2 Admissions
- 4.1 Discharges
- 5 Interpretation of Studies
- 6 Procedures
- 7 Pediatric Medical Decision Making
Macros or dot phrases may be imported into Orchid/Cerner to expedite charting.
Medical Screening Exam
The patient was seen in triage for _
Labs/imaging ordered to evaluate for a cause of this complaint.
Vital signs reviewed, patient awake and alert in NAD.
History of present illness
CHIEF COMPLAINT: _
Hx obtained from: _
Made better/worse by: _
Social: _denies regular alcohol, tobacco, or illicit substance abuse
Basic Adult physical exam
Vital signs stable
General: Patient is well nourished, well developed, awake and alert, resting comfortably in no acute distress
Head: Normocephalic and atraumatic
Eyes: Normal inspection, extraocular muscles intact, no conjunctival pallor
Ear, nose, throat: Normal external exam
Neck: Normal range of motion
Respiratory: Patient is in no respiratory distress, lungs CTAB
Cardiovascular: Patient is not tachycardic, RRR without murmur appreciated
GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion
Back: Normal inspection of the back with good strength and range of motion throughout all ext
Extremities: pulses intact with good cap refills, no LE pitting edema or calf tenderness
Neuro: The patient is alert and oriented to person, place, and time, appropriately conversive, with 5/5 bilat UE/LE strength, no gross motor or sensory defects noted. Coordination appears to be adequate.
Skin: Warm, dry, and intact
Adult Medical Decision Making
The patient is oriented to person, place, and time, has the capacity to make decisions regarding the medical care offered. 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. 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).
I have reviewed the relevant issues with the patient. They are aware of the suspected diagnosis suggested by screening exam, [_], based upon the initiated medical screening exam. The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. The recommended medical care being refused has been discussed with the patient and is [_]. 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 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.
[Discharge instructions were provided to the patient.] 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.
General Abdominal Pain with CT
This patient presents with abdominal pain of unclear etiology. A CT scan was performed to evaluate for potential causes of the abdominal pain, however, neither the clinical exam nor the CT has identified an emergent etiology for the abdominal pain. 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. 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.
General Abdominal Pain without CT
This patient presents with abdominal pain of unclear etiology. Their evaluation has not identified a emergent etiology for the abdominal pain. 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. 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. 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. 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.
Abdominal Pain in Females
_yo G_P_ woman at _weeks gestational age by _LMP/ultrasound presenting with abdominal pain. 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.). 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.). Patient well-appearing with normal vital signs. Patient is Rh ***and therefore requires/does not require RhoGAM. Gave patient strict return precautions for worsening pain, increased vaginal bleeding, fever (temperature above 100.4F), lightheadedness/syncope or other concerns. For consideration of ectopic pregnancy, the quantitative beta hCG was _and therefore was above/below the discriminatory zone of 1,500 mIU/mL. Transvaginal/transabdominal ultrasound demonstrated _. Patient will follow up in 48 hours with their obstetrician.
_yo non-pregnant woman presenting with abdominal pain. Given patient’s pregnancy test is negative, highly doubt ectopic pregnancy. 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.). 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.). Patient well-appearing with normal vital signs. Laboratory testing and imaging here reviewed and normal. Patient given strict return precautions for worsening pain, inability to eat/drink, fevers (temperature over 100.4F), or other concerns. Patient instructed to follow up with their primary doctor and is agreeable; all questions were answered.
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. We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. We also discussed returning to the Emergency Department immediately if new or worsening symptoms occur. 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.
Low-risk Chest Pain
This patient presents with chest pain that is very unlikely angina or acute coronary syndrome. The emergency department evaluation has not identified any cause for suspicion that this chest pain has a cardiac etiology. 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. 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. 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.
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. Other life-threatening diagnoses have been considered. 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.
Chest Pain Cardiac with negative troponin (low HEART score)
The patient presented with chest pain of uncertain etiology. Based on their history, lab analysis, EKG (which showed no evidence of ischemia or infarction), and imaging, in addition to the patient's physical exam, I see no evidence at this time for a malignant etiology for the patient's chest pain. 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.
[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. It is highly likely that cardiac enzymes would be abnormal in chest pain of this duration if their chest pain was attributable to ACS.] [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).] HEART score _0-3.
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. 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. 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. The importance of close follow up was also discussed with the patient.
Shortness of Breath Asthma/COPD
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. 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. Using prediction rules for syncope, this patient is safe for discharge and outpatient evaluation.
Nature of occupational exposure:
Part 1: Type of Exposure
Non-infectious body fluids are saliva, sputum, urine, vomitus, nasal secretions, sweat, tears, and feces. However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious.
Potentially infectious body fluids are blood and CSF.
A. Needle type (solid or hollow bore): _
B. Gauge: _
C. Had needle been in contact with patient’s blood or potentially infectious body fluid (yes/no)? _
D. Specify body fluid type: _
E. If not blood, was body fluid bloody (yes/no)? _
F. Was there visible blood on the needle (yes/no)? _
G. Depth of needlestick (no visible penetration, shallow penetration, deep puncture)? _
H. Was the employee wearing gloves (yes/no)? _
Scalpel wound: _
A. Did the scalpel have the blood or potentially infectious body fluid on it (yes/no)? _
Mucosal exposure/splash in eyes, mouth, nose: _
A. Was the exposure/splash to blood or potentially infectious body fluid? (yes/no)? _
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)? _
Part 2: Details Regarding the Source Patient
Full name of source patient: _
MRN of source patient: _
Diagnosis or reason source patient is under care: _
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): _
Is source patient known to be Hepatitis C Ab positive (yes/no)? _
If yes, is source patient known to be Hepatitis C RNA positive (yes/no)? _
Is source patient known to be Hepatitis B surface AG positive (yes/no)? _
MDM 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): _
A. 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. _
B. Near zero risk because it was limited to exposure to a non-infectious body fluid. _
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. _
D. Near zero risk because sharp object (e.g., needle or scalpel) did not penetrate skin. _ _ 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.
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. _
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. _
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. _
_ MDM for a clinically meaningful exposure:
_ [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. 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 will not perform any laboratory testing on the exposed employee in the ED.
_ [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. If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc.), 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. 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. 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. 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 will not perform any laboratory testing on the exposed employee in the ED.
A. Harbor-UCLA Medical Center employees: Employee Health next working day _ (ORCHID Message sent to Employee Health, Erika Sweet)
B. UCLA Medical Students: UCLA Student Health _
C. Prehospital Care Providers and Law Enforcement: Refer to their contracted occupational health provider _
Non-employees: Refer to their Primary Care Provider _
Interpretation of Studies
The airway was evaluated and head placed in neutral position. The patient was preoxygenated and suction was available. Immediately prior to intubation, [Etomidate] (induction agent) and [Rocuronium] (neuromuscular blocking agent) were administered. The cords were directly visualized using a [size 3 MacIntosh blade] and a [7.5mm] cuffed endotracheal tube was placed via the orotracheal route. Tube marked at cm at the lip. There were no complications. 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. Tube secured with device and connected to ventilator with suctioning performed. Given [propofol] for post-intubation sedation.
- Chest Tube
Pediatric Medical Decision Making
Discussed with _ natural course of fever with viral illness, fever's function in body in fighting viral pathogens, my concern more for how a patient appears and acts (lethargy, irritability no po intake) as opposed to specific height of fever, expectation that fever will return when antipyretics wear off and normality of that occurrence, and appropriate dosing of antipyretics.
Head Trauma (No CT)
Glasgow coma scale 15. No hematoma. No skull crepitance or stepoff. No Battle sign. No raccoon eyes. No fluid from nose or ears. No nasal septal hematoma. No open wounds. No cervical spine tenderness. Risks of CT radiation far outweigh any risks of intracranial hemorrhage. Given instructions regarding supportive care including pain meds as needed, return precautions, follow-up with primary physician.
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.