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. Cerner’s physician solutions include more than 40 specialties – created by physicians for physicians – to drive efficiency and productivity. _ The importance of close follow up was also discussed with the patient. Learn more about how we change the way health and care is being delivered, inside and out of the ED. Epic Cerner EPOWERdoc . Ear, nose, throat: Normal external exam In this book you will find dot phrases for all primary care specialties. Their evaluation has not identified a emergent etiology for the abdominal pain. Part 1: Type of Exposure The cords were directly visualized using a [size 3 MacIntosh blade] and a [7.5mm] cuffed endotracheal tube was placed via the orotracheal route. 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) ! _ 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. 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. Other life-threatening diagnoses have been considered. Cerner FirstNet is positioned to address these challenges. However, if these fluids are contaminated with visible blood, then they are to be considered potentially infectious. Vital signs reviewed, patient awake and alert in NAD. Creating your own dot phrase It’s also very helpful to create your own smartphrases. Coordination appears to be adequate. Skin: Warm, dry, and intact. If the source patient is unable to participate in an opt-out discussion (sedated, altered, etc. We’re uniquely positioned to develop the solutions and services that enhance efficiency and simplify communications among care team members. bilat UE/LE strength, no gross motor or sensory defects noted. The Smart Phrase Database. Reply. 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. /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. October 5, 2020 ... Command Center Medicine to Improve Emergency Department Patient Flow. Electronic Medical Record Smart Phrases, Note Templates, and Dot Phrases created by Emergency and Family Medicine physicians through clinical experience. in no acute distress This patient presents with abdominal pain of unclear etiology. Follow up: We have discussed the diagnosis and risks, and we agree with discharging home to follow-up with their primary doctor. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. Neuro: The patient is alert and oriented to person, place, and time, appropriately conversive, with 5/5 Designed by ED clinicians for ED clinicians. Transvaginal/transabdominal ultrasound demonstrated _. 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. Creating your own dot phrase It’s also very helpful to create your own smartphrases. Macros or dot phrases may be imported into Orchid/Cerner to expedite charting. GI: Abd SNT with no guarding or rebound; +BS normoactive x 4, no tympanny to percussion Sweet Cerner Tricks. “We know the readmission penalties,” said Kim King, SMMC Administrative Director of Care Coordination. 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. We need you! The patient acknowledges understanding of the reasons for recommendations regarding medical treatment, medical testing, and further monitoring and observation. 2. 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