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SMART PHRASES

 

Smart phrases don’t make you smart, but they help you document important recurrent facts efficiently and they help prevent  you from forgetting to document some of the care you provide.  I typically use smart phrases as starting points and then adjust them to fit each patient.

The smart phrases below are organized chronologically: History, Exam, Procedures, Disposition.

Spanish ACI have recently been added.

Feel free to use the phrases below as starting points and then modify as you see fit.  If you have suggestions for improvements on my phrases below or requests to add additional smart phrases go ahead and leave a comment or email me at safetydoc@gmail.com.

 

ADULT REVIEW OF SYSTEMS:

  • GENERAL: No Fever. No Generalized Weakness. 
  • RESPIRATORY: No Chest Pain. No SOB
  • CARDIAC: No Palpitations. No Syncope
  • GASTROINTESTINAL: No Abdominal Pain. No Melena
  • NEUROLOGIC: No Focal Weakness.
  • PSYCHIATRIC: No Hallucinations. Not Suicidal
  • ALL OTHER SYSTEMS REVIEWED & NEGATIVE EXCEPT AS IN PMH & HPI

PEDIATRIC REVIEW OF SYSTEMS:

  • General: No Fever. No Weakness
  • Respiratory: No Cough. No SOB
  • GI: No Abdominal Pain. No Vomiting
  • Skin: No Rash
  • ALL OTHER SYSTEMS REVIEWED AND NEGATIVE EXCEPT AS IN PMH & HPI

TRAUMA REVIEW OF SYSTEMS:

  • Constitutional: No Fever. No Weakness.
  • Cardiac: No Syncope. No Palpitations.
  • Respiratory: No Shortness of breath. No Chest pain.
  • Gastro-intestinal: No Abdominal pain. No Vomiting.
  • Musculo-skeletal: No Arm pain. No Leg pain. No Neck or Back pain
  • Psychiatric: No Hallucinations. No Suicidal thoughts
  • All other systems reviewed and are negative except as noted in HPI and PMH

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ADULT EXAM:

  • GENERAL: Alert, calm, conversant in NAD
  • HEAD: Normocephalic, atraumatic
  • EYES: Clear without discharge. No photophobia
  • ENT: No stridor, drooling, trismus or dysphonia. Moist
  • NECK: Trachea midline. Supple
  • CHEST: No tenderness
  • LUNGS: Unlabored respirations.  No splinting. No rales.  No wheezing.
  • HEART: Normal rate. Regular. Normal heart sounds.
  • ABDOMEN: Soft, non-tender. No guarding. No rebound
  • GENITOURINARY: No CVAT
  • SPINE: No deformity noted.
  • EXTREMITIES: No edema. No tenderness. Homan’s negative. Symmetric pulses
  • NEUROLOGIC: Normal speech. No focal weakness. Alert and oriented.
  • PSYCHIATRIC: Normal mood. No SI
  • SKIN: No erythema.
  • LOCATION/COMPANY:

PEDIATRIC EXAM:

  • General: Alert, calm, happy in NAD
  • Head: Normocephalic, atraumatic
  • Eyes: Clear without discharge. No photophobia
  • ENT: No stridor, drooling, trismus or dysphonia. Moist
  • Neck: Trachea midline. Supple
  • Chest: No tenderness
  • Lungs: Unlabored respirations. No splinting. Clear. No splinting. No rales or wheezing.
  • Heart: Normal rate. Regular. Normal heart sounds.
  • Abdomen: Soft, non-tender. No guarding. No rebound
  • GU: No CVAT
  • Extremities: No edema or tenderness. Symmetric pulses
  • Neuro: Normal speech. No focal weakness.
  • Skin: No rash.
  • LOCATION/COMPANY:

TRAUMA EXAM:

  • LOCATION/COMPANY:
  • General: Conversant and cooperative. In no acute distress.
  • Vitals: Triage note and vitals reviewed.
  • Head: Normocephalic. Atraumatic.
  • Eyes: Clear. No Discharge. No Photophbia
  • ENT: No stridor, drooling, hoarse voice, swelling or trismus.
  • Neck: No tracheal deviation. Not Tender. No Bruising.
  • Cardiac: Normal rate. Regular rhythm. Normal heart sounds.
  • Chest: Effort normal. No Respiratory distress. No Splinting. No Wheezing. No Rales.
  • Abdominal: Soft. No guarding. No rebound. Not Tender. No Bruising.
  • Musculoskeletal: No Edema. No Tenderness.
  • Neurological: Alert and oriented. Non-focal. Normal speech.
  • Skin: Warm and dry. No erythema. No Abrasions
  • Psychiatric: Normal mood and affect.

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SEPSIS RE-EXAM:

If on pressors or lactate  is greater than 4 document volume status with 1 of the 3 below with time

  1. Ultrasound for volume status 
  2. CVP & ScVO2 
  3. Sepsis Re-Exam (below)                           
  • Chest Exam:   heart rate, lung sounds
  • Vital Signs:     stable / improved / concerning
  • Pulses:            strong / thready
  • Skin Signs:     warm & dry / cool / diaphoretic
  • Cap Refill:      <2 seconds / >2sec

ADMISSION COURSE & COUNSELING:

  • GENERAL: Patient and/or family informed regarding my recommendation for admission and the reasons why.  Preliminary exam and test findings conveyed and questions answered.  Case discussed with admitting physician and any consultants. Bed type, ED treatment and further ED workup decided by joint decision making with admitting team and any consultants.
  • STABILITY: Patient stable for admission per my assessment and discussion with admitting physician and any consultants.
  • PLAN: Joint plan of care made in consensus with admitting physician and any consultants, including what management will be deferred to the inpatient setting.

TRANSFER COURSE & COUNSELING:

  • STABILITY: Patient stable for transfer per my assessment.  This was also discussed with the accepting provider at the receiving facility.
  • RISKS & BENEFITS: Risks, benefits and alternatives and reason for transfer discussed with patient by me and registration.

POINT OF CARE ULTRASOND

  • I performed a point of care limited study of the ORGAN in order to evaluate for possible INDICATION. 
  • The following findings were note: FINDINGS. 
  • Images were saved and archived for further review and evaluation.

OBSERVATION NOTE:

  • Patient was observed for more than 4 hours in the emergency department to determine whether or not admission was indicated.
  • The patient and re-examined on at least 2 separate occasions.  

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SHARED DECISION MAKING

  • Benefits of advanced imaging or other additional testing versus home observation discussed with patient and/or family.
  • Shared decision making with patient and her family occurred. Advanced imaging not deemed necessary based on clinical scenario at this time.
  • Patient/family realizes that they may need to return later today or tomorrow to have imaging done if they are worse or not improving

DISCHARGE COURSE & COUNSELING:

  • COURSE: Patient remained stable in the emergency department and at discharge is tolerating oral intake at their baseline. No significant issues raised by nurse remained unresolved.  There is currently no evidence of an emergency medical condition based on the medical screening exam.  The patient and/or family were updated and are comfortable with the plan of care. 
  • COUNSELING: The patient and/or family was counseled on the diagnosis, treatment and side effects (especially for any sedating medications), restrictions, need for follow-up and reasons to return here to the ED.  They were also told to call their PCP or referral doctor today or tomorrow for more advice and/or to arrange follow-up appointment.  If blood pressure was elevated they were counseled on the importance of having this rechecked as an outpatient.
  • TEST RESULTS: The patient and/or family was told that they needed to have any abnormal test results repeated with a follow-up doctor and that they need to have that doctor also obtain and discuss with them their final radiology reports and/or the final results of any cultures or other tests that were still pending at the time of discharge.  Copies of their preliminary lab and imaging reports were provided at discharge.

TYPE “D” PATIENT (Difficult)

  • Patient had multiple questions. I did my best to answer all of them.
  • Significantly more than the usual amount of time was spent trying to explain testing and results diagnosis or lack there of plan for follow-up and further outpatient care and especially reasons to return to the emergency department

TYPE “E” PATIENT  (Easy)

  • Patient was extremely pleasant and appreciative.
  • He or she felt reassured and was comfortable with the plan for further care and follow-up if needed.

IV CONTRAST & METFORMIN (GLUCOPHAGE) or related combo meds:

  • You received IV contrast for the CT scan we did today.  On rare occasions IV contrast can cause damage to your kidney.  This usually is not detectable for at least 2 days and if it occurs it usually resolves within 2 weeks.
  • Many health care providers falsely believe that after IV contrast you only need to stop metformin for 48 hours.  This is incorrect.  If you are told this, you should ignore it.
  • You can take your metformin today, but after that do not take it until your doctor rechecks your kidney function and tells you it has not worsened.  This testing should be done 3-5 days from now.  Taking metformin with decreased kidney function can be deadly.
  • Call your doctor today or tomorrow for more advice and to see if he or she wants to start you on a substitute medication for your diabetes for the time being.

RETURN PRECAUTIONS & AFTERCARE: (ENGLISH)

  • RETURN PRECAUTIONS: Return immediately to the emergency department or call your doctor if you feel worse, weak or have changes in speech or vision, are short of breath, have fever, vomiting, pain, bleeding or dark stool, trouble urinating or any new issues.
  • FOLLOW-UP CARE: Call your doctor and/or any doctors we referred you to for more advice and to make an appointment.  Do this today, tomorrow or after the weekend.  Some doctors only take PPO insurance so if you have HMO insurance, unless you want to pay cash, you may want to contact your HMO or your regular doctor for referral to a specialist within your plan.  Be sure to tell them it was a referral from the emergency department so you get the soonest possible appointment.  
  • YOUR TEST RESULTS: Take copies or reports of any test done today, including blood or urine tests, imaging tests and EKG’s to your doctor and any referral doctor. You should have any abnormal tests repeated.  Your doctor or a referral doctor can let you know when the test should be repeated.  Also make sure your doctor contacts this hospital to get other test results such as labs that were not yet resulted and final imaging reports, which are usually not available at the time you leave the emergency department, and which may contain additional important findings not documented on the preliminary imaging report.  If your blood pressure was greater than 120/80 have your blood pressure rechecked within 1 to 2 weeks.
  • MEDICATION SIDE EFFECTS: Do not drive, walk, bike, take the bus, etc. if you have received or are being prescribed any sedating medications such as those for pain or anxiety or certain  antihistamines like Benadryl.  If you have been give one of these here get a taxi home or have a friend drive you home.

PRECAUCIONES PARA VOLVER Y SEGUIMIENTO: (ESPAÑOL)

  • PRECAUCIONES DE DEVOLUCIÓN: Regrese inmediatamente al departamento de emergencias o llame a su médico si se siente peor, débil, le falta el aliento, o tiene fiebre, vómitos, dolor, sangrado o heces oscuras, dificultad para orinar o cualquier problema nuevo.
  • ATENCIÓN DE SEGUIMIENTO: Llame a su médico y/o a los médicos que lo referieron para obtener más información y para programar una cita. Haz esto hoy, mañana o después del fin de semana. Varios medicos solo toman un seguro PPO, si usted tiene un seguro HMO debe comunicarse con su HMO o su médico primario para que lo envie a un especialista de acuerdo a su plan medico, de no ser asi tendria que pagar en efectivo por la consulta. Asegúrese de decirles que fue una referencia del departamento de emergencias para que pueda obtener la cita más pronto posible. Si su presión arterial fue superior a 120/80, vuelva a verificar su presión arterial dentro de 1 a 2 semanas.
  • SUS RESULTADOS DE LOS ESTUDIOS: Lleve copias o informes de cualquier examen realizado hoy, incluidos análisis de sangre u orina, imágenes y electrocardiogramas, a su médico y a cualquier médico de referencia. Debe repetir las estudios anormales. Su médico o un médico de referencia pueden informarle cuándo se debe repetir el estudio. Además, asegúrese de que su médico se comunique con este hospital para obtener otros resultados de estudios, como laboratorios que aún no se han realizado, e informes finales de imágenes, que pueden contener resultados importantes adicionales no documentados en el informe de emergencia preliminar.
  • CÓMO LLEGAR A CASA DE MANERA SEGURA: No conduzca, camine o tome el autobús a su hogar si ha recibido algún medicamento sedante, como medicamentos para la ansiedad o ciertos analgésicos o antihistamínicos como Benadryl. Si este es el caso, consiga un taxi a casa o haga que un amigo lo lleve a su casa.

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INFORMED REFUSAL OF TEST OR PROCEDURE:

  1. Reason: The patient has decided to refuse a treatment or procedure because ______.
  2. Capacity: The patient has normal mental status and adequate capacity to make medical decisions.
  3. Risks: Risks of refusal have been explained including  permanent disability and death.
  4. Benefits: Benefits have also been explained, including the ability to determine the best treatment.
  5. Understanding: The patient was able to verbalize understand and state the risks and benefits
  6. Witnesses: Nurse _________ and family _________.
  7. Questions: The patient had the opportunity to ask questions
  8. Plan B: The patient was treated to the extent they allow and knows they may change their mind

AMA DISCHARGE:

  1. Reason: The patient has decided to leave against medical advice because ______.
  2. Capacity: The patient has normal mental status and adequate capacity to make medical decisions.
  3. Refusal: The patient refuses hospital admission and wants to be discharged.
  4. Risks: Risks have been explained including ____, worsening illness, permanent disability and death.
  5. Benefits: Benefits of admission have also been explained
  6. Understanding: The patient verbalized understanding the risks and benefits of hospital admission.
  7. Witnesses: Nurse _________ and family _________.
  8. Questions: The patient had the opportunity to ask questions about their medical condition.
  9. Plan B: The patient was treated to the extent they allow and knows they may return at any time
  10. Follow-up: Follow-up has been discussed and arranged with Dr. ___________.

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 FOR EVEN MORE SMART PHRASES GO TO MDMACROS.COM AND SELECT EMERGENCY MEDICINE OR CLICK HERE

 

 

 

 

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