Department of Emergency Medicine | University of Washington
HMC/UWMC ED Sample Dot Phrase TemplatesVersion June 2017Contact UW EM Chiefs with questions (uwemchiefs@)9/6/17GENERAL CONCEPTS OF DOCUMENTATION IN EM AT HMC/UWMCThere are different documentation requirements for different levels of billing (level 1 billing reflects lowest level of complexity/physician time/involvement; level 5 represents highest level of complexity/time/involvement). HPI –Level 1-3 (one element)Level 4-5 (four elements) ROS – (Please do not use the word “points” when describing)Level 1 – not requiredLevel 2-3 – one system (not required if problem pertinent +/- documented in HPI)Level 4 – 2 systemsLevel 5 – 10+ systems Physical ExamLevel 1 – one systemLevel 2-3 – 2 systemsLevel 4 – 5 systemsLevel 5 – 8 systems High Acuity caveat documentation-- it is acceptable to use these phrases when appropriate if you are unable to complete portions of the HPI or PE:unable to obtain history due to …unable to perform full exam due to … (crashed to OR, Cath lab, etc) Please tailor your specific ROS and Physical Exam documentation to reflect exactly what you asked / did/ saw! As part of your MDM, please include the differential diagnoses that you considered.MDM coding is based on -Number of diagnosis and management optionsChart reviewed (indicate in MDM that records/chart reviewed and notable for/summarized as follows….)Risk SAMPLE ROS DOT PHRASES Example statements for ROS (pick whichever systems you actually reviewed):3/14 Review of Systems completed and negative except as stated above in the HPI (Systems reviewed: Resp, CV, GI) 10/14 Review of Systems completed and negative except as stated above in the HPI (Systems reviewed: HENT, Eyes, Resp, CV, GI, GU, MSK, Skin, Neuro, Psych)ROS (10 systems)In addition to that documented in the HPI above, the additional ROS was obtained:Constitutional: Denies fevers or chillsEyes: Denies vision changesENMT: Denies sore throatCV: Denies chest painResp: Denies SOBGI: Denies vomiting or diarrheaGU: Denies painful urinationMSK: Denies recent traumaSkin: Denies new rashesNeuro: Denies new numbness or tingling or weaknessEndocrine: Denies unexpected weight lossHeme: Denies bleeding disorders ROS (6 systems)In addition to that documented in the HPI above, the additional ROS was obtained:Constitutional: Denies fevers or chillsEyes: Denies vision changesENMT: Denies sore throatCV: Denies chest painResp: Denies SOBGI: Denies vomiting or diarrheaSAMPLE PHYSICAL EXAM TEMPLATE DOT PHRASESBare-bones Physical Exam - Add in your further exam findings:[VS here]I have reviewed the triage vital signs.Const: Well nourished, well developed, appears stated ageEyes: PERRL, no conjunctival injectionHENT: NCAT, Neck supple without meningismus CV: RRR, Warm, well-perfused extremitiesRESP: CTAB, Unlabored respiratory effortGI: soft, non-tender, non-distended, no massesMSK: No gross deformities appreciatedSkin: Warm, dry. No rashesNeuro: Alert, CNs II-XII grossly intact. Sensation and motor function of extremities grossly intact.Psych: Appropriate mood and affect.TRAUMA EXAMVital signsGENERAL: On backboard with C-collar in place.SKIN: Warm and well perfused. No rashes, bruises, discolorations or abrasions.HEAD: Atraumatic, normocephalic without edema, discoloration or evidence of trauma. Facial bones without deformities or tenderness. EYES: PERRL. No scleral icterus or conjunctival injection. Extraocular muscles intact without nystagmus or diplopia. No proptosis or enophthalmos.EARS: Normal appearing pinnae. No hemotympanum.NOSE: No discharge, tenderness, laxity. No nasal septal hematoma.MOUTH: No malocclusion or trismus. Moist mucus membranes without blood. Posterior pharynx without erythema or exudate.NECK: Trachea midline. No discolorations or edema. Neck immobilized in cervical collar.CV: Regular rate and rhythm, Normal s1 and s2. No murmurs, rubs, or gallops.PV: Radial pulses 2+ bilaterally and symmetric. Dorsalis pedis pulses 2+ bilaterally and symmetric. 2+ capillary refill. No extremity edema.CHEST: No abrasions or ecchymosis. Chest symmetric with respirations. No chest wall tenderness. No crepitus. No step offs. Lungs are clear to auscultation bilaterally. No rales, rhonchi, wheezing or stridor.ABDOMEN: No ecchymosis or abrasions. Soft, nondistended, nontender. Bowel tones normoactive. No masses or organomegaly.BACK: No abrasions, skin openings, or ecchymosis. Spine without bony tenderness, no step offs.PELVIC: Pelvis stable, nontender to lateral compression and palpation of symphysis pubis.RECTAL: Normal tone. Stool without gross blood.GU: Normal external genitalia without blood at meatus. No ecchymosis or edema.MSK: No gross deformities or discolorations or lesions. Tolerates full range of motion of extremities without tenderness. NEURO: Alert and oriented to person, place, and time. GCS 15. CN II-XII intact. Sensation grossly intact. Strength 5/5 in bilateral UE and LE. Finger to nose intact bilaterally. INFANT EXAMVitalsConstitutional: (location of infant), NAD, active, vigorousEYES: PERRL. Sclera non-icteric. Conjunctiva non-injected. No discharge.HENT: NCAT. Fontanelles flat. MMM. TMs clear bilaterally No cervical LAD. Neck supple without meningismus.CV: RRR, no M/R/GResp: No increased WOB. CTAB.GI: Normoactive bowel sounds. Soft, NT/ND, no masses or organomegaly appreciated.GU: Normal external female anatomy OR circumcised/uncircumcised penis. Testes descended and appear to be non-tender bilaterally.MSK: No gross deformities appreciated.Neuro: Alert, age appropriate. Normal muscle tone. Moving all extremities.Skin: No rashes. CHILD EXAMVitalsConstitutional: Well developed, NADEYES: PERRL. Sclera non-icteric. Conjunctiva not injected. No discharge.HENT: NCAT. MMM. Posterior oropharynx non-erythematous, no tonsillar exudates. TMs clear bilaterally, canals normal. No cervical LAD. Neck supple without meningismus.CV: RRR, no M/R/G, 2+ pulses in distal radius and DP pulses equal bilaterallyResp: No increased WOB. Lungs CTAB.GI: Normoactive bowel sounds. Soft, NT/ND, no masses or organomegaly appreciated.GU: Normal external female anatomy OR circumcised/uncircumcised penis. Testes descended and non-tender bilaterally.MSK: No gross deformities appreciated.Neuro: Alert, age appropriate. Normal muscle tone. Moving all extremities.Skin: No rashes. PSYCH/MENTAL STATUS EXAMAppearance: Well kemptBehavior: Calm, good eye contact, in no acute distressMood: (patient describes)Affect: (blunted, pleasant, angry) Mood is (congruent/discongruent) with affect.Speech: Appropriate rate, quantity and volume.Thought process: LinearThought content: (what is on patient’s mind). Denies SI/HI.Cognition: NormalInsight: GoodJudgment: Good HAND EXAM (detailed)Symmetrically palpable radial and ulnar pulses. Capillary refill <2 seconds to all digits.Intact sensation to light touch of the radial, median and ulnar nerves demonstrated by testing in the dorsal web space of the thumb, the distal palmar aspect of the index finger, and the lateral surface of the fifth finger.2 point discrimination intact to 5mm (up to 6mm can be normal in digits 3-5) of discrimination in the affected digit.Intact motor function of the radial, median and ulnar nerves demonstrated by strength of extension of the isolated distal joint of the index finger, hand grip, and spreading of the 2nd through 5th digits. Intact recurrent median nerve as demonstrated by ability to move thumb fully through opposition, abduction and flexion.No snuffbox tenderness. EYE EXAM (detailed)Visual Acuity: OD 20/20; OS 20/20; (wearing glasses/contacts (finger counting, motion, light perception))Visual Fields:OD intact x 4; OS intact x 4Extraocular movements: OD intact w/o diplopia; OS intact w/o diplopiaLids/Lashes/Lacrimal: OD no lesions; OS no lesionsConjunctiva & Sclera: OD white and quiet; OS white and quietCornea: OD no fluorescein uptake;OS no fluorescein uptakeAnterior chamber: OD deep and quiet; OS deep and quietIris: OD round and reactive; OS round and reactiveLens: OD clear; OS clearRetina: OD sharp disc margins (unable to visualize); OS sharp disc margins (unable to visualize)Intraocular pressure: OD ___; OS ____Eye Exam (alternative layout)Eye Exam:RightLeftExternal:NormalNormalSlit Lamp Exam:- Lids/LashesNormalNormal- Conjunctiva / scleraWhite, quietWhite, quiet- CorneaClearClear- Anterior ChamberDeep, quietDeep, quiet- IrisNormalNormal- LensNormal Normal- VitreousNormalNormal Fundus:- DiscNormalNormal- VesselsNormalNormal- PeripheryNormalNormal Visual Acuity:__Both: _ Visual Fields:__Tonometry:__ NEURO EXAM (detailed)Mental status: A/Ox3CN II-XII tested and intact.Sensation intact to sharp/dull differentiation in all extremities.Motor: Normal tone and bulk. No abnormal movements appreciated. No pronator drift. Strength tested and 5/5 in bilateral wrist flexion/extension, elbow flexion/extension, shoulder abduction, straight leg raise, knee flexion/extension, ankle dorsiflexion/plantarflexion. Patient ambulates with a steady gait.Coordination: Finger to nose and heel to shin testing intact bilaterally.Reflexes: Brachioradialis, biceps, and patellar reflexes WNL and symmetric bilaterally. Babinski with downgoing toes bilaterally. RECTAL EXAM (for cauda equina – insert into adult exam):Symmetric intact sharp/dull differentiation to both sides of perineum. Normal rectal tone. Stool/no stool in rectal vault. PELVIC EXAMExternal genitalia unremarkable.Speculum exam with normal appearing whitish vaginal discharge.Vaginal wall mucosa is unremarkable.Cervix visualized and is unremarkable (closed in appearance without any protruding material).Bimanual exam without cervical motion tenderness, adnexal tenderness or any masses appreciated.(Swabs for testing for gonorrhea, chlamydia and wet prep were obtained.) SAMPLE MDM TEMPLATES SEPSIS RE-EVALUATIONDate:Time:BP:HR: CHRONIC PAIN MDM“I discussed the patient's recurrent pain issues with @him@. This is the *** time @name@ has been evaluated in the emergency department for pain-related issues in the last ***. I emphasized that my training was in the treatment of acute pain, that @his@ physical exam here is quite reassuring, and that definitive treatment of chronic pain is not the role of the emergency department. “@He@ exhibited the following behaviors known to be associated with addiction and pseudoaddiction: ***- inability to restrict medications or take them on an agreed-upon schedule ***- taking multiple medications together ***- doctor shopping ***- the use of nonprescribed psychoactive drugs in addition to prescribed medications ***- noncompliance with recommended nonopioid treatments or evaluations ***- a preoccupation with opioids ***- insistence on rapid-onset formulations and routes of administration ***- reports of allergy or no relief whatsoever by any nonopioid treatments I compassionately explained to @name@ that I felt providing opiate medications from the emergency department was counterproductive in that this may cause or exacerbate tolerance, acute overdose, physiological or psychological dependence, or withdrawal. We discussed that opiate use in the management of chronic pain is best managed by a single practitioner, such as a primary care provider or a pain specialist. We discussed adjunctive therapies such as heat, ice, and exercise, as well as non-opiate medications such as acetaminophen, NSAIDs, antidepressants, gabapentin, and pregabalin. I reiterated to @name@ that the most effective management of @his@ chronic pain involves a multimodal approach coordinated by @his@ primary care provider and often includes physical therapy, cognitive behavioral therapy, and referrals to practitioners such as anesthesiologists trained in chronic pain management. SNUFFBOX TENDERNESSThe patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ hand. XR obtained and is negative. However, due to concern for an occult scaphoid fracture, the patient was placed in a thumb spica splint and instructed to follow up with their PCP for repeat exam and radiography in 10-14 days. Discussed this concern with the patient and emphasized the importance of keeping the hand splinted and obtaining appropriate follow up. ALCOHOL INTOXICATIONPatient presented with altered mental status, smelling of alcohol with documented history of alcohol dependence. They arrived afebrile, with stable vital signs. Bedside glucose check without evidence of severe derangement. No signs of trauma or other etiology of altered mental status on initial exam. Patient was monitored with serial exams for several hours while they cleared their alcohol and altered mental status. Repeat exam benign. Patient then demonstrated ability to ambulate safely, tolerated oral intake, and articulated a safe discharge plan. Discharged to self-care, with return precautions for any new or concerning symptoms. DISCHARGEPt was discharged home/self-care.Pt was discharged with the following prescriptions: _____.Pt was provided written discharge instructions. Additional verbal instructions were given and discussed with Pt including, but not limited to, _____. Pt was asked to return to the ED immediately for any new or concerning or if they worsen.Pt was in agreement, endorsed understanding, and questions were answered.Pt instructed to follow-up with ____(PCP/Specialist) within _____days. SAMPLE FULL GENERAL ED NOTE TEMPLATEID/CC:_ HISTORY OF PRESENT ILLNESS:_ PAST MEDICAL HISTORY:_ MEDICATIONS:Medications from chart: [ *MEDS - Home ] ALLERGIES: [ *Allergies List ]FAMILY HISTORY:_ SOCIAL HISTORY:_ REVIEW OF SYSTEMS: In addition to that documented in the HPI above, the additional ROS was obtained:Constitutional: Denies fevers or chillsEyes: Denies vision changesENMT: Denies sore throatCV: Denies chest painResp: Denies SOBGI: Denies vomiting or diarrheaGU: Denies painful urinationMSK: Denies recent traumaSkin: Denies new rashesNeuro: Denies new numbness or tingling or weaknessEndocrine: Denies unexpected weight lossHeme: Denies bleeding disorders PHYSICAL EXAM: *Vital Signs - SCCA I have reviewed the triage vital signsConst: Well nourished, well developed, appears stated ageEyes: PERRL, no conjunctival injectionHENT: NCAT, Neck supple without meningismus CV: RRR, Warm, well-perfused extremitiesRESP: CTAB, Unlabored respiratory effortGI: soft, non-tender, non-distended, no massesMSK: No gross deformities appreciatedSkin: Warm, dry. No rashesNeuro: Alert, CNs II-XII grossly intact. Sensation and motor function of extremities grossly intact.Psych: Appropriate mood and affect.EKG:_ CONSULTS:Time called: _MDM:_DIAGNOSIS:_DISPOSITION:_----------------------------------------------------------------------------------------------------SAMPLE PROCEDURE NOTE TEMPLATES PROCEDURE NOTE: INCISION AND DRAINAGE OF ABSCESSIndication: AbscessOperator: _Indications, risks, and benefits explained to patient and verbal informed consent obtained.Correct patient and procedure type was verified.1) The patient was anesthetized using _ cc lidocaine 1% w/epinephrine 2) Abscess Location: _ 3) Abscess Size: _ 4) Procedure description: _ 5) Culture specimen(s) obtained and sent for testing? _ Yes _ NoA clean dressing was applied.The patient tolerated the procedure with some discomfort. PROCEDURE NOTE: LACERATION REPAIRIndication: LacerationOperator: _Indications, risks, and benefits explained to patient and verbal informed consent obtained.Laceration location & length: _Anesthesia was performed with 1% lidocaine with epinephrine.The wound was irrigated with _cc of NS under pressure.The patient was prepped and draped in usual fashion.Repair type:_ Simple: repair involving routine debridement & decontamination, simple one layer closure, superficial tissues, sutures/staples/tissue adhesives, total length of several repairs in same code category._ Intermediate: closure of contaminated single layer wound, layer closure (e.g. SQ tissue, superficial fascia), removal foreign material (e.g. gravel, glass), routine debridement & decontamination, simple exploration nerves/blood vessels/tendons in wound._ Complex: creation of defect for repair such as scar removal, debridement complicated wounds/avulsions, more complicated than layered closure, simple exploration nerves/vessels/tendons in wound or vessel ligation in wound, undermining/stents/retention sutures.Number and type of sutures placed: _FAST examIndication: Blunt Abdominal TraumaNo FF in RUQ, LUQ, pericardial, or pelvic windowsQuality of imaging obtained: _Interpretation: _Attending Physician interpreting: _[_] Images saved to hard drive and uploaded to digital archiveFocused Cardiac UltrasoundIndication: _ Cardiac Arrest _ Other:Qualitative assessment of cardiac performance: [_] Good [_] Fair [_] Poor [_] StandstillPericardial Effusion: _NoneCardiac Tamponade: _None evidentQuality of imaging obtained: _Interpretation: _Attending Physician interpreting: _[_] Images saved to hard drive of ultrasound machineFocused Soft Tissue UltrasoundIndication: suspected cellulitis vs. abscessQuality of imaging obtained: _Interpretation: _Attending Physician interpreting: _[_] Images saved to hard drive and uploaded to digital archiveFocused 1st Trimester OB UltrasoundIndication: _The patient was positioned in standard fashion.Findings:Structures visualized:_ Gestational sac_ Yolk sac_ Fetal poleFHR: _ bpmEGA: _ weeks by :[_] CRL [_] BPD [_] HC [_] FLOther:_Quality of imaging obtained: _Interpretation: _Attending Physician interpreting: _[_] Images saved to hard drive and uploaded to digital archiveUS-guided peripheral venous cannulationCandidate vein examined with linear array probe - confirmed collapsibility, lack of pulsatility, and proper anatomic location. [_] Local anesthesia provided via infiltration of 1% lidocaine w/o epiUsing aseptic technique, IV catheter inserted with flash of blood noted, flow of venous blood confirmed. Flushes easily and without pain. No hematoma or complications noted. Patient tolerated well.[_] Images saved to hard drive and uploaded to digital archiveGeneral Abdominal US examIndication: Preprocedure ultrasound for paracentesisRUQ- [_] +FFSubxyphoid- [_] +FFLUQ- [_] +FFPelvic- [_] +FFQuality of imaging obtained: _Interpretation: Large amount of free fluid. No clear evidence of bowel adhesions to abdominal wallAttending Physician interpreting: _[_] Images saved to hard drive and uploaded to digital archiveThoracic UltrasoundExam Indication: preprocedure ultrasound evaluation for thoracentesisRight hemithorax- [_] +FFLeft hemithorax- [_] +FFQuality of imaging obtained: _Interpretation: free fluid in the [_] Right [_] Left hemithorax. No clear evidence of pleural adhesionsAttending Physician interpreting: _[_] Images saved to hard drive and uploaded to digital archive PROCEDURE NOTE: ARTHROCENTESIS - KNEEIndication: (side) knee pain, concern for septic arthritisOperator: _Indications, risks, and benefits explained to patient and informed consent obtained.The (side) knee was prepped with chlorhexadine, and sterile drapes were applied to the area. The skin and subcutaneous tissue was anesthetized with 1% lidocaine with epinephrine. An 18 gauge needle was then inserted lateral to the patella into the joint space, and fluid was aspirated. Approximately ___ mL of ____ fluid was obtained. The needle was removed and a dressing was placed over the site. The patient tolerated the procedure well. PROCEDURE NOTE: DENTAL BLOCKIndication: dental painOperator: Verbal consent obtained from patient.A 22g needle was used to inject bupivacaine into the region of the ___inferior alveolar nerve (apical portion of the affected tooth).Patient tolerated the procedure well. PROCEDURE NOTE: FRACTURE REDUCTION & SPLINTINGIndication: _Operator: _Indications, risks, and benefits explained to patient and informed consent obtained. (Emergent procedure; unable to obtain consent.)Pre-procedure neurovascular exam:A time out was performed.(Describe reduction)Post procedure neurovascular exam:The patient tolerated the procedure well. PROCEDURE NOTE: PHYSICIAN PLACEMENT OF PERIPHERAL IV -EXTERNAL JUGULARIndication: difficult to access - nursing staff unable to secure PIVOperator: Location: (side) External jugular veinPt provided verbal consent for IVUsual prep with chlorhexidine18g IV placed on first attempt. Flash noted, and catheter advanced smoothly into the vein.NS saline flushed without resistance, witnessed swelling, or patient discomfortIV secured with I-site and tegadermThe patient tolerated the procedure well. PROCEDURE NOTE: PHYSICIAN PLACEMENT OF ULTRASOUND GUIDED PERIPHERAL IVIndication: difficult to access - nursing staff unable to secure PIVOperator: _Location: _Pt provided verbal consent for IVStatic views used to identify the target veinUsual prep with chlorhexidine2cc 1% lidocaine local block to facilitate procedure20g long IV placed on first attempt under dynamic US guidance. Dark red flash noted, and catheter advanced smoothly into the veinNS saline flushed without resistance, witnessed swelling, or patient discomfortIV secured with I-site and tegadermThe patient tolerated the procedure well. PROCEDURE NOTE: SHOULDER REDUCTIONIndication: (anterior/posterior) dislocation of (side) shoulderOperator: _Indications, risks, and benefits explained to patient and informed consent obtained.Radiographs were obtained showing dislocation.Pre procedure, patient had intact motor & sensation of median, radial and ulnar nerves, with intact sensation of axillary nerve.Joint was reduced without anesthesia with return of normal alignment.Post procedure, patient had intact motor & sensation of median, radial and ulnar nerves, with intact sensation of axillary nerve.Patient was placed in a sling, and instructed to follow up with primary care within 1 week. PROCEDURE NOTE: FINGER REDUCTIONIndication: (side, joint, finger dislocation)Operator: _Indications, risks, and benefits explained to patient and informed consent obtained.Pre procedure, patient had intact 5mm two-point discrimination to the radial and ulnar aspect of the affected finger.A digital block was performed with lidocaine.The finger was reduced with traction, and was splinted in extension.A post reduction sensory exam was not obtained due to the digital block. The patient was able to fully flex and extend the previously dislocated digit.The finger was splinted, which they were instructed to wear for 4 days.Post reduction XR was without evidence of fracture.The patient tolerated the procedure well. ................
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