DOCUMENTATION

 

Documentation Macros are organized by ED visit chronology as follows:

  • H & P: Review of Systems & Physical Exam macros for adult, peds & trauma
  • MDM: Shared decision-making, HEART score, MIPS, ED status
  • Dispo: Admit, Transfer, Discharge (English & Spanish versions)
  • AMA/Refusals: includes AMA order to avoid AMA w/o printed ACI
  • Supervision: PA/NP Supervision, Resident supervision
  • Next Day: Culture results & Call Back macros
  • Other: Telemedicine & Urgent Care macros
  • More: links to macros from other websites

Feel free to copy/paste the phrases below and then modify as you see fit.  If you have suggestions for improvements or requests to add additional macros  email me at safetydoc@gmail.com. 

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H & P MACROS

ADULT REVIEW OF SYSTEMS:

  • GENERAL: No Fever. No Generalized Weakness.
  • RESPIRATORY: No Chest Pain. No SOB
  • CARDIAC: No Palpitations. No Syncope
  • GI: No Abdominal Pain. No Melena
  • NEURO: 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:

  • GENERAL: No Fever. No Weakness.
  • CARDIAC: No Syncope. No Palpitations.
  • RESPIRATORY: No Shortness of breath. No Chest pain.
  • GI: No Abdominal pain. No Vomiting.
  • ORTHOPEDIC: No Arm pain. No Leg pain. No Neck or Back pain
  • PSYCHIATRIC: No Hallucinations. No Suicidal thoughts
  • ALL OTHER SYSTEMS REVIEWED AND NEGATIVE EXCEPT AS IN PMH & HPI

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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
  • LUNGS: Unlabored respirations.  No splinting. No rales.  No wheezing.
  • HEART: Normal rate. Regular. Normal heart sounds.
  • CHEST: No tenderness
  • 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
  • LUNGS: Unlabored respirations. No splinting. Clear. No splinting. No rales or wheezing.
  • HEART: Normal rate. Regular. Normal heart sounds.
  • CHEST: No tenderness
  • 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:

  • GENERAL:Conversant and cooperative. In no acute distress.
  • VITALS: Triage note and vitals reviewed.
  • HEAD: Normocephalic. Atraumatic.
  • EYES: Clear. No Discharge. No Photophobia
  • ENT: No stridor, drooling, hoarse voice, swelling or trismus.
  • NECK: No tracheal deviation. Not Tender. No Bruising.
  • LUNGS: Effort normal. No Respiratory distress. No Splinting. No Wheezing. No Rales.
  • CARDIAC: Normal rate. Regular rhythm. Normal heart sounds.
  • CHEST: No tenderness
  • ABDOMEN: Soft. No guarding. No rebound. Not Tender. No Bruising.
  • EXTREMITIES: No Edema. No Tenderness. No deformity.
  • NEURO: Alert and oriented. Non-focal. Normal speech.
  • SKIN: Warm and dry. No erythema. No Abrasions
  • PSYCHIATRIC: Normal mood and affect.
  • LOCATION/COMPANY:

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MDM MACROS

POINT OF CARE ULTRASOUND:

  • 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.

SEPSIS RE-EXAM:

If on pressors or lactate >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

OBSERVATION NOTE:

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

Waiting Room Medicine macro:

This patient is being initially evaluated by me in the ED waiting room as there are no beds currently available in the main ED.  I have ordered monitoring, lab/radiology studies, and/or IV therapy, and have informed the Charge Nurse that this patient needs to be roomed as soon as one can be made available.  I have asked the patient to notify the nursing staff immediately of any concerns or any changes in their symptoms.

COVID MACRO:

The patient was evaluated during the global COVID-19 pandemic, and that diagnosis among others was considered. Their evaluation, testing and treatment was consistent with current but daily evolving CDC and other guidelines for patients who present with symptoms or signs that may be related to COVID-19.

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

HEART score macro: HEART Score =

  2 Points 1 Point 0 Points
History Highly suspicious Moderately suspicious Slightly suspicious
ECG ST depression Nonspecific ST or T, BBB… Normal
Age >65 years 45-65 years <45 years
Risk factors 3+ risk factors** 1-2 risk factors** N0 risk factors**
Troponin* >2x URL < URL Undetectable

MIPS for 2023: Merit Based Incentive Payment System (Head to Toe)

MIPS SUMMARY for 2023:

  1. Head trauma: Document indication for head CT.  Acceptable reasons below for adults and peds
    • Adult: severe HA, vomit, mechanism, thin blood, low platelets, focal deficit, e/o skull fx, age?65
    • Age<18: document “patient NOT low risk according to PECARN criteria”
  2. Stroke:  Arrival w/in 2h of onset: give TPA w/in 3h of last known well time, or a reason why not
  3. Pregnancy:   If pregnant w/ pelvic pain or bleeding an ultrasound documents the pregnancy location.  Exceptions: patient has previously documented intrauterine pregnancy
  4. Sinusitis: Document indication if ABX given: facial cellulitis, immunocompromised, sick >10 days
    • If an ABX is prescribed, use amoxicillin or document a reason: allergy, recent amox…
    • If Sinus CT ordered document reason: sick >28 days, trauma, concern for abscess…
  5. Otitis externa: Document that only topical ABX were used.  If oral ABX, document reason: can’t see TM, w/ otitis media, cellulitis, perforation
  6. Bronchitis: If an ABX is prescribed, document reason: COPD, immunosuppression, structural lung dz, age >65

MIPS FOR STROKE

  • The patient arrived at the hospital within 3.5 hours of time last known well, was diagnosed with ischemic stroke. IV t-PA was initiated within 4.5 hours of time last known well time.
  • The patient was diagnosed with subacute or acute ischemic stroke. IV t-PA was NOT initiated within 4.5 hours of last known well due to [select]:
    • Patient arrived more than 3.5 hours after last known well time or the time last known well is unknown
    • Patient has a contra-indication or reason for not administering [****] (ex. neurologist does not believe t-PA appropriate, active internal bleeding, serious head trauma, acute current or history of intracranial hemorrhage, uncontrollable hypertension, seizure at onset of stroke, CVA or Intracranial or intraspinal surgery in last 3 months, bleeding disorder, thrombocytopenia <100,000, early radiographic ischemic changes, INR > 1.7, intracranial neoplasm, AVM, or aneurysm)
    • Patient or family declined IV t-PA

MIPS FOR ADULT HEAD TRAUMA

  • [] Head CT NOT ordered 
  • [] Head CT ordered because:
    • [] Patient is 65 or older
    • [] Patient GCS <15  [] Patient has focal neurologic deficit
    • [] Patient has severe headache  [] Patient is vomiting
    • [] Severe/dangerous mechanism of injury was identified (List mechanism)
    • [] Signs of basilar skull fracture (hemotympanum, raccoon eyes, CSF leak, Battle’s sign)
    • [] Anticoagulant medication [] thrombocytopenia [] coagulopathy
    • [] Loss of consciousness PLUS one of the following: [] Headache [] memory deficit [] intoxication [] trauma above clavicles [] Age >60 [] seizure
  • [] Head CT ordered for reasons other than trauma
  • [] Patient excluded from MIPS because: [] VP shunt [] brain tumor [] multi-system trauma [] antiplatelet medication 

MIPS FOR PEDIATRIC HEAD TRAUMA

  • [] Head CT NOT ordered by emergency care clinician
  • [] Patient is between 2-17 years, presenting with minor blunt head trauma. Head CT was ordered for trauma AND:
    • [] Patient NOT classified as low risk according to PECARN prediction rule   
    • [] Head CT ordered for reasons other than trauma
  • [] Patient is between 2-17 years, presenting with minor blunt head trauma but is excluded from MIPS because (list one of below)
    • [] Patient has ventricular shunt, [] Patient has brain tumor, [] Patient is taking antiplatelet medication 

MIPS FOR SINUSITIS 

  • [] The patient has sinusitis and antibiotics are NOT indicated/NOT prescribed at this time.
  • [] The patient has sinusitis with symptom onset greater than 10 days ago and the patient was prescribed antibiotics.
  • [] Patient was prescribed an amoxicillin-based antibiotic.
  • [] Patient was prescribed a non-amoxicillin-based antibiotic because [****] (ex. allergy, intolerance, secondary infection)
  • [] The patient has sinusitis and was prescribed antibiotics because [****] (ex. symptoms worsened after improving,  secondary infection, patient is immunocompromised)
  • [] Patient was prescribed an amoxicillin-based antibiotic.
  • [] Patient was prescribed a non-amoxicillin-based antibiotic because [****] (ex. allergy, intolerance, Cellulitis, UTI…)

MIPS FOR OTITIS EXTERNA 

  • [] The patient has Acute Otitis Externa and was NOT prescribed oral/systemic antibiotics today.
  • [] The patient has Acute Otitis Externa and was prescribed oral/systemic antibiotics because [****] (ex. immunity, other ID)

MIPS FOR URI 

  • [] The patient was diagnosed with upper respiratory infection and was NOT prescribed or dispensed an antibiotic.
  • [] The patient has competing comorbid condition within the last 12 months. The comorbid condition was [****]
  • [] The patient is already on antibiotics, or has taken them within the last 30 days.
  • [] The patient had a competing diagnosis of [****] (e.g. acute otitis media, chronic sinusitis, cellulitis, UTI…)

MIPS FOR BRONCHITIS

  • [] The patient has acute bronchitis/bronchiolitis and antibiotics were NOT prescribed or dispensed today.
  • [] The patient has acute bronchitis/ bronchiolitis. Antibiotics were prescribed or dispensed because the patient meets one of the following:
  • [] Patient has a medical reason for prescribing or dispensing an antibiotic. That reason is [****] (ex. COPD, bacterial ID….)
  • [] Patient is currently on antibiotics or has been in the last 30 days.
  • [] Patient’s visit resulted in an inpatient admission.

MIPS FOR PREGNANCY

  • [] The patient is pregnant and presents with abdominal pain or vaginal bleeding. A pelvic ultrasound was performed and the pregnancy location is documented.
  • [] The patient is pregnant and presents with abdominal pain or vaginal bleeding. A pelvic ultrasound was NOT performed because patient has previously documented IUP

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DISPOSITIONS MACROS

DISCHARGE AFTERCARE MACRO:

IMPORTANT: EVEN THOUGH WE THINK IT IS SAFE FOR YOU TO GO HOME, NO EVALUATION OR TEST IS PERFECT SO THERE IS ALWAYS A SMALL CHANCE THAT YOU WILL NEED TO RETURN AND BE HOSPITALIZED.  THEREFORE IT IS VERY IMPORTANT THAT IF YOU GET WORSE OR DEVELOP ANY NEW SYMPTOMS THAT YOU RETURN HERE AS SOON AS POSSIBLE TO BE RE-EVALUATED.  THIS INCLUDES THE RETURN OF SYMPTOMS THAT HAVE RESOLVED SUCH AS FAINTING, CHEST PAIN OR SYMPTOMS THAT COULD BE A WARNING FOR A STROKE.

RETURN PRECAUTIONS: Return here or see/call your doctor if not improving as expected, but return here immediately and/or contact a primary care doctor if you get worse, develop any new symptoms or have any of the following:

  1. – Weakness or changes in speech/vision/coordination 
  2. – Shortness of breath, chest pain or fainting
  3. –  One or both legs/feet become swollen, cold or painful
  4. – Vomiting, dark stool, bleeding or trouble urinating
  5. – Fever or chills, or if already present fever >103 or lasting >4-5 days
  6. – New, changing or migrating pain

 

FOLLOW-UP CARE: We often don’t make a definite diagnosis in the ER.  You will need a second opinion if you do not get better and usually even if you do.  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.  If you have HMO insurance, you may want to contact your HMO or your primary care doctor for referral to a specialist within your plan.  Either way tell the doctor’s office that it was a referral from the emergency department to get the soonest possible appointment.

YOUR TEST RESULTS: Take result reports of any blood or urine tests, imaging tests and EKG’s to your doctor and any referral doctors. Have any abnormal tests repeated.  Your doctor or a referral doctor can let you know when this should be done.  Also make sure your doctor contacts this hospital to get any test results that are not yet available such as culture results or special tests for infection and final imaging reports, which are often not available at the time you leave the ER but which may list additional important findings that are not on the preliminary report.

BLOOD PRESSURE & GLUCOSE: If your blood pressure was greater than 120/80 or your glucose level was >100 have it rechecked within 1 to 2 weeks.  The stress of your current condition can often cause a temporary rise in blood pressure or glucose level, but many people have undiagnosed hypertension or pre-diabetes.

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.  Ask your pharmacist to counsel you on potential side effects of any new medication.  If you are being prescribed antibiotics take a probiotic or eat yogurt and realize birth control pills may be less effective.

WHAT IF I DON’T GET BETTER: Even with the best laid treatment plan, there is typically a 5-10% chance that you will not improve as expected or even get worse.  If you get worse you should return here as soon as possible; the wait is typically shortest in the morning.  If you stay the same or only improve partially, instead of returning here it may be reasonable to see a primary care provider for follow-up care and a second opinion.

 

PRECAUCIONES DE DEVOLUCIÓN Y CUIDADO POSTERIOR: (SPANISH)

IMPORTANTE: AUNQUE CREEMOS QUE ES SEGURO PARA USTED VOLVER A CASA, NINGUNA EVALUACIÓN O PRUEBA ES PERFECTA POR LO QUE SIEMPRE HAY UNA PEQUEÑA POSIBILIDAD DE QUE DEBE REGRESAR Y SER HOSPITALIZADO. POR LO TANTO ES MUY IMPORTANTE QUE SI EMPEORA O DESARROLLA ALGÚN SÍNTOMA NUEVO QUE REGRESE AQUÍ LO ANTES POSIBLE PARA SER REEVALUADO. ESTO INCLUYE EL RETORNO DE SÍNTOMAS QUE SE HAN RESUELTO COMO DESMACHE, DOLOR EN EL PECHO O SÍNTOMAS QUE PODRÍAN SER UN AVISO DE ACV.

PRECAUCIONES DE REGRESO: Regrese aquí o vea/llame a su médico si no mejora como se esperaba, pero regrese aquí inmediatamente y/o comuníquese con un médico de atención primaria si empeora, desarrolla síntomas nuevos o tiene alguno de los siguientes:

– Debilidad, cambios en el habla/visión/coordinación o dificultad para orinar
– Dificultad para respirar, dolor en el pecho o hinchazón de las piernas
– Vómitos, sangrado o heces oscuras
– Fiebre o escalofríos, o si la fiebre ya está presente, sube >103 o dura >4-5 días en total
– Dolor nuevo, cambiante o migratorio

ATENCIÓN DE SEGUIMIENTO: A menudo no hacemos un diagnóstico definitivo en la sala de emergencias. Necesitará una segunda opinión si no mejora y, por lo general, incluso si mejora. Llame a su médico y/o a cualquier médico al que lo hayamos derivado para obtener más consejos y programar una cita. Haz esto hoy, mañana o después del fin de semana. Si tiene un seguro HMO, es posible que desee comunicarse con su HMO o con su médico de atención primaria para que lo deriven a un especialista dentro de su plan. De cualquier manera, dígale al consultorio del médico que fue una remisión del departamento de emergencias para obtener la cita lo antes posible.

LOS RESULTADOS DE SUS PRUEBAS: Lleve los informes de resultados de cualquier prueba de sangre u orina, pruebas de imágenes y electrocardiogramas a su médico y a cualquier médico que lo remita. Repita cualquier prueba anormal. Su médico o un médico de referencia puede informarle cuándo debe hacerse esto. También asegúrese de que su médico se comunique con este hospital para obtener los resultados de las pruebas que aún no están disponibles, como resultados de cultivos o pruebas especiales para detectar infecciones e informes finales de imágenes, que a menudo no están disponibles en el momento en que sale de la sala de emergencias, pero que pueden incluir información adicional importante. Hallazgos que no están en el informe preliminar.

PRESIÓN ARTERIAL Y GLUCOSA: Si su presión arterial era superior a 120/80 o su nivel de glucosa era >100, hágalo volver a controlar dentro de 1 a 2 semanas. El estrés de su condición actual a menudo puede causar un aumento temporal de la presión arterial o del nivel de glucosa, pero muchas personas tienen hipertensión o prediabetes no diagnosticadas.

EFECTOS SECUNDARIOS DE LOS MEDICAMENTOS: No conduzca, camine, ande en bicicleta, tome el autobús, etc. si ha recibido o le han recetado medicamentos sedantes, como los que se usan para el dolor o la ansiedad, o ciertos antihistamínicos como Benadryl. Si le han dado uno de estos aquí, tome un taxi a casa o pídale a un amigo que lo lleve a casa. Pídale a su farmacéutico que le aconseje sobre los posibles efectos secundarios de cualquier medicamento nuevo. Si le recetan antibióticos, tome un probiótico o coma yogur y tenga en cuenta que las píldoras anticonceptivas pueden ser menos efectivas.

¿QUÉ PASA SI NO MEJORO? Incluso con el mejor plan de tratamiento establecido, normalmente hay entre un 5 y un 10 % de posibilidades de que no mejore como se esperaba o que incluso empeore. Si empeora, debe regresar aquí lo antes posible; la espera suele ser más corta por la mañana. Si permanece igual o solo mejora parcialmente, en lugar de regresar aquí, puede ser razonable consultar a un proveedor de atención primaria para recibir atención de seguimiento y una segunda opinión.

 

ADMISSION MEDICAL DECISION MAKING: (“DOCTORS” mnemonic)

  • 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.
  • DOCTORS
    • DDx:               Differential diagnoses including chronic illnesses impacting care
    • Others:          History obtained from Other people: family, medics, nursing home, caregiver…
    • Consults:      Consultants including Radiologist, Hospitalists, PMD…
    • Test/Tx:         Independent interpretations of Tests and their significance
    • Outside:        Outside records reviewed including Old labs, Office notes…
    • Rx:                  Treatment considered, even if not done
    • Social:           Social determinants of health, Social work consults
    • Summary:

TRANSFER MACRO:

  • STABILITY: Patient is stable for transfer per my assessment.  This was also discussed with the following specialists: ___________
  • RISKS: Risks of transfer discussed with patient including traffic accidents an delays in care.
  • Benefits: Benefits of transfer discussed with patient including continuity of care, financial benefits, and if applicable higher level of care.
  • Patients decision: If lateral transfer, patient informed that it is completely up to him or her if they want to be transferred and that it is their decision not the decision of myself or the staff at this hospital.

DISCHARGE COURSE & COUNSELING:

  • COURSE: Patient remained stable and at discharge is tolerating oral intake at their baseline and is not deemed to have a fall risk. No significant issues raised by nursing remained unresolved.  Based on an appropriate medical screening exam there is currently no evidence of an emergency medical condition, but return precautions were given in case things change.  The patient and/or family were updated and are comfortable with the plan of care.  They were told to wait for their paperwork.
  • 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.  They were also told to call their PCP or referral doctor as soon as possible for more advice and/or to arrange a follow-up appointment and to have them obtain formal radiology reports and pending lab test results including cultures.  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.
  • RE-EXAM: Repeat exam at time of discharge shows:
  • DDx:               Differential diagnoses including chronic illnesses impacting care
  • Others:          History obtained from Other people: family, medics, nursing home, caregiver…
  • Consults:      Consultants including Radiologist, Hospitalists, PMD…
  • Test/Tx:         Independent interpretations of Tests and their significance
  • Outside:        Outside records reviewed including Old labs, Office notes…
  • Rx:                  Treatment considered, even if not done
  • Social:            Social determinants of health, Social work consults
  • More:              –   MIPS documentation:
        • HEART score =
        • Observation Notes:

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.

 

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AMA & REFUSALS

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 ORDER:

  • AMA DISCHARGE ORDER – have patient AND family member BOTH sign the AMA form if possible.  DO NOT discharge patient without aftercare and prescription if added.

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: If possible the patient’s PCP was called to help try to convince them to stay in the hospital and to arrange appropriate follow-up care.

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SUPERVISION & NEXT DAY MACROS

PA/NP ATTESTATION macros: NEW ATTESTATIONS FOR 2024

 

Supervision Only Attestation:  (The majority of charts sent for co-signature.  We never speak with the PA/NP nor have face to face with the patient.)

Physician Attestation:  I was available for consultation/guidance on patient care.  Based on the medical record, the care appears appropriate.

 

Supervision with Guidance Attestation:  (Cases where the PA/NP discusses the case with you, but you don’t actually have face to face interaction with the patient.)

I performed a substantive part of the MDM during the patient’s E/M visit. I personally made or approved the documented management plan and acknowledge its risk of complications.

  • My (EKG/X-Ray/US/CT) interpretation __________.
  • Management/test interpretation discussed with __________.

Supervision with Face to Face Attestation:  (Cases where you have face to face interaction with the patient.)

I performed a substantive part of the MDM during the patient’s E/M visit. I personally evaluated and examined the patient. I personally made or approved the documented management plan and acknowledge its risk of complications.

  • My (EKG/X-Ray/US/CT) interpretation __________.
  • Management/test interpretation discussed with __________.

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LWOT & CULTURE RESULT CALL-BACK macros

Spoke to Patient: Patient/Family called back to see how they are doing and answer any question. I spoke to the patient. I recommended return to the emergency department as soon as possible or if they did not feel the need, to instead follow up with a primary care doctor today or as soon as possible. When appropriate, I also recommended they go to the patient portal to get any test results and to see a primary care provider to discuss any abnormal results.

Message Left: Patient/Family called back to see how they are doing and answer any question.  There was no answer but I was able to leave a message. I recommended return to the emergency department as soon as possible or if they did not feel the need, to instead follow up with a primary care doctor today or as soon as possible. When appropriate, I also recommended they go to the patient portal to get any test results and to see a primary care provider to discuss any abnormal results.

No Message Left: Patient/Family called back to see how they are doing and answer any question.  There was no answer and no option to leave a message.

 

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OTHER: TELEMEDICINE & URGENT CARE

TELEMEDICINE VIDEO VISIT

  • History of Present Illness: 
  • Past Medical History:
  • Medications/Allergies: 
  • Social & Family History: 

TREATMENT PLAN:

REVIEW OF SYSTEMS:

  • GENERAL: No Fever. No Weakness
  • CHEST: No Chest Pain. No SOB. No Palpitations. No Syncope
  • GI: No Abdominal Pain. No Melena.
  • PSYCH: No Hallucinations. Not Suicidal
  • ALL OTHER SYSTEMS NEGATIVE EXCEPT AS IN PMH & HPI

EXAM:

  • SPECIFIC:
  • GENERAL: Alert, calm, conversant in NAD
  • HEAD: Normocephalic, atraumatic
  • EYES: Clear without discharge. No photophobia
  • ENT: No stridor, drooling, trismus or dysphonia.
  • NECK: Trachea midline. Supple
  • LUNGS: Unlabored respirations, speaking in full sentences
  • NEURO: Normal speech. No focal weakness. Alert and oriented.
  • PSYCHIATRIC: Normal mood. Normal insight and judgement.

COUNSELING & AFTERCARE:

  • COUNSELING: The patient/parent was counseled on the diagnosis, treatment and side effects, restrictions, and need for PCP follow-up as soon as possible. 
  • FOLLOW-UP & ER PRECAUTIONS: The patient and/or parent was counseled to see a primary care doctor or go to the emergency department if worse, weakness, short of breath, vomiting, not improving or any new issues.

 

TELEMEDICINE TELEPHONE VISIT

  • History of Present Illness: 
  • Past Medical History:
  • Medications/Allergies: 
  • Social & Family History: 

TREATMENT PLAN:

REVIEW OF SYSTEMS:

  • GENERAL: No Fever. No Weakness
  • CHEST: No Chest Pain. No SOB. No Palpitations. No Syncope
  • GI: No Abdominal Pain. No Melena.
  • PSYCH: No Hallucinations. Not Suicidal
  • ALL OTHER SYSTEMS NEGATIVE EXCEPT AS IN PMH & HPI

EXAM:

  • SPECIFIC:
  • GENERAL: Alert, calm, conversant in NAD
  • ENT: No stridor or dysphonia.
  • LUNGS: Unlabored respirations, speaking in full sentences
  • NEURO: Normal speech. Alert and oriented.
  • PSYCHIATRIC: Normal mood. Normal insight and judgement.

COUNSELING & AFTERCARE:

  • COUNSELING: The patient/parent was counseled on the diagnosis, treatment and side effects, restrictions, and need for PCP follow-up as soon as possible. 
  • FOLLOW-UP & ER PRECAUTIONS: The patient and/or parent was counseled to see a primary care doctor or go to the emergency department if worse, weakness, short of breath, vomiting, not improving or any new issues.

 

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URGENT CARE macros:

DISCHARGE COURSE & COUNSELING:

  • COURSE: Patient remained stable and at discharge is tolerating oral intake at their baseline and is not deemed to have a fall risk. Based on an appropriate medical screening exam there is currently no evidence of an emergency medical condition but ER precautions were given in case things change.  The patient/family were updated and are comfortable with the plan of care.
  • COUNSELING: The patient/family was counseled on the diagnosis, treatment and side effects (especially for sedating medications), restrictions, need for follow-up and reasons to return here or go to the ER.  They were also told to call their PCP or referral doctor as soon as possible for more advice and/or to arrange a follow-up appointment and to have them obtain formal radiology reports and pending lab test results.  If blood pressure was elevated they were counseled on the importance of having this rechecked as an outpatient.
  • TEST RESULTS:The patient/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.
  • RE-EXAM & CONSULTS:

 

RETURN PRECAUTIONS & AFTERCARE: (ENGLISH)

  • RETURN PRECAUTIONS: Go immediately to the ER or see/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.  Return here or see/call your doctor if not improving as expected for your suspected condition.
  • FOLLOW-UP CARE: Call your doctor and/or any doctors we referred you to for more advice or to make an appointment.  Do this today, tomorrow or after the weekend.  If you have HMO insurance you may want to contact your HMO or your regular doctor for referral to a specialist within your plan.  Either way tell the doctor’s office that it was a referral from urgent care so you get the soonest possible appointment.
  • YOUR TEST RESULTS: Take result reports of any blood or urine tests, imaging tests and EKG’s to your doctor and any referral doctor. Have any abnormal tests repeated.  Your doctor or a referral doctor can let you know when this should be done.  Also make sure your doctor contacts us to get any test results that are not currently available such as cultures or special tests for infection and final imaging reports, which may not be available at the time you leave but which may list additional important findings not documented on the preliminary report.
  • BLOOD PRESSURE: 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.  Ask your pharmacist to counsel you on potential side effects of any new medications.

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From RobOrman.com:

 

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