FreeState – Admission Note

Chief Complaint: [text size="50"]

HISTORY OF PRESENT ILLNESS
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Patient is a [text size="3" ]-year-old [select value="male|female"] that is being admitted to hospital medicine [select value="from the Emergency Department.|at the request of primary care.|from an outside facility."]  [textarea name="hpi" default=""] 

[comment memo="ED LABS AND DIAGNOSTICS"][checkbox name="Problem1" value="ED vital signs, imaging, labs, and administered medications reviewed."]

[comment memo="ED IMAGING"][checkbox name="Problem800" value="ED Imaging: 
No imaging collected in ED."][checkbox name="Problem801" value="Chest X-Ray:"] [conditional field="Problem801" condition="(Problem801).is('Chest X-Ray:')"][checkbox value="no acute abnormalities|infiltrate indicative of PNA|pleural effusion|cardiomegaly|pulmonary edema/overload"]. 
[textarea name="cxr" default=""][/conditional] 
[checkbox name="Problem802" value="CT Head:"] [conditional field="Problem802" condition="(Problem802).is('CT Head:')"][checkbox value="no acute abnormalities|abnormal findings per radiology"]. [textarea name="cthead" default=""][/conditional]
[checkbox name="Problem88" value="CT Abd/Pel:"] [conditional field="Problem88" condition="(Problem88).is('CT Abd/Pel:')"][checkbox value="non-contrast study performed|contrast study performed|no acute abnormalities|abnormal findings per radiology"]. [textarea name="ctabd" default=""][/conditional]
[checkbox name="Problem89" value="CT Chest:"] [conditional field="Problem89" condition="(Problem89).is('CT Chest:')"][checkbox value="non-contrast study performed|contrast study performed|angiography performed|no acute abnormalities|abnormal findings per radiology"]. [textarea name="ctchest" default=""][/conditional]
[comment memo="ED LABS"] 
[checkbox name="Problem803" value="ED Labs: 
No labs collected in ED."]
[checkbox name="Problem804" value="CBC:"] [conditional field="Problem804" condition="(Problem804).is('CBC:')"][checkbox value="is unremarkable|shows leukocytosis|with anemia|low platelets|with bandemia|is at patients baseline"].  [textarea name="cbc" default=""][/conditional] 
[checkbox name="Problem805" value="Chemistry:"] [conditional field="Problem805" condition="(Problem805).is('Chemistry:')"][checkbox value="unremarkable|hypoglycemia|hyperglycemia|hyponatremia|hypernatremia|hypokalemia|hyperkalemia|HAGMA|elevated BUN|elevated Cr|transaminitis|hypomagnesmia"]. [textarea name="cmp" default=""][/conditional] 
[checkbox name="Problem806" value="UA:"] [conditional field="Problem806" condition="(Problem806).is('UA:')"][checkbox value="negative preg|positive preg|without s/s of infection|positive leukocytes|positive nitrates|positive protein|positive glucose|positive ketones|+ THC|+ meth|+ opiates|+ benzos"]. [textarea name="ua" default=""][/conditional] 
[checkbox name="Problem807" value="Troponin:"] [conditional field="Problem807" condition="(Problem807).is('Troponin:')"][checkbox value="negative|elevated"]. [textarea name="trop" default=""][/conditional] 

[comment memo="SEPSIS"][checkbox name="Problem1001" value="Sepsis Risk:"] [conditional field="Problem1001" condition="(Problem1001).is('Sepsis Risk:')"][checkbox value="Patient with criteria indicative of SIRS/Sepsis|Patient without indication of SIRS/Sepsis|given 30ml/kg fluids in ED|was not given 30ml/kg of fluids in ED due to contraindication:|did receive abx in the ED: |did not receive antibiotics in the ED|initial lactic acid negative| initial lactic acid elevated| procalcitonin collected in ED| procalcitonin not collected in ED|inital blood cultures collected in ED|no blood cultures collected in ED"]. [text size="80"][/conditional]

[comment memo="EKG"][checkbox name="Problem11" value="EKG"] [conditional field="Problem11" condition="(Problem11).is('EKG')"][select name="EKG" value="reviewed-"] [conditional field="EKG" condition="(EKG).is('reviewed-')"][checkbox value="normal sinus rhythm|atrial fib rate controlled|atrial fib with RVR|tachycardia|bradycardia|normal axis|left axis deviation|right axis deviation|PR interval normal|QRS complex normal|No relevant ST segment deviation/elevation|QT interval not prolonged"]. [text size="80"][/conditional]

PATIENT HISTORY
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PMHx: [checkbox name="variable_2" value="No PMHx"]
[checkbox name="variable_1" value="HTN|HLD|A fib|CHF|CAD|COPD|Asthma|Allergic Rhinitis|GERD|Migraines|Seizure Disorder|DM|Hypothyroidism|Dementia|Osteoarthritis|Chronic pain|Depression|Anxiety|Insomnia|alcohol abuse|tobacco use"] [text default="" size="60"]

PSHx: [checkbox value="reviewed|noncontributory"]
[checkbox name="passurg" value="Chole|appy|tonsillectomy|TAH|TKA|THA|cardiac stents|lumbar fusion|cataract removal"] [text default="" size="60"]

FMHx: [checkbox value="reviewed|noncontributory"]
[checkbox name="Problem67" value="Mother:"] [conditional field="Problem67" condition="(Problem67).is('Mother:')"][text name="variable_1" default=""][/conditional]
[checkbox name="Problem68" value="Father:"] [conditional field="Problem68" condition="(Problem68).is('Father:')"][text name="variable_1" default=""][/conditional]
[checkbox name="Problem69" value="Siblings:"] [conditional field="Problem69" condition="(Problem69).is('Siblings:')"][text name="variable_1" default=""][/conditional]

Social Hx: [checkbox value="reviewed"]
Tobacco: [select name="Tobacco" value="Has never used tobacco products.|Is a previous tobacco user.|Is a current every day smoker.|Is a current vape user.|Is a user of chewing tobacco."] [text default="" size="60"]
ETOH: [select name="EtOH" value="Denies current use.|Reports to using alcohol socially.|Reports previous abuse of alcohol.|Reports to current daily use of alcohol."] [text default="" size="60"]
Illicit Drugs: [select name="illicitdrugs" value="Denies use.|Reports previous use.|Reports current use."] [text default="" size="60"]

Living situation: [text default="" size="60"]

REVIEW OF SYSTEMS
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[checkbox name="ros" value="Patient denies"] [conditional field="ros" condition="(ros).is('Patient denies')"] [checkbox value="fever|chills|malaise|chest pain|palpitations|shortness of breath|cough|wheezing|abd pain|nausea|vomiting|diarrhea|constipation|vertigo|headache|confusion|blurry vision"][/conditional]

10-point ROS negative except per HPI.

[checkbox name="gen" value="GENERAL:"] [conditional field="gen" condition="(gen).is('GENERAL:')"] [checkbox value="Well-groomed, well-appearing patient, in no acute distress|Pediatric|Adult|Elderly|male patient|female patient|laying in bed|sitting at bedside|up in chair|well-groomed|well-appearing|chronically-ill in appearance|acutely ill in appearance|appears uncomfortable|appears in pain|toxic in appearance|in moderate distress|in no acute distress"].
[textarea name="gen" default=""][/conditional]
[checkbox name="ski" value="SKIN:"] [conditional field="ski" condition="(ski).is('SKIN:')"] [checkbox value="Warm, dry and intact. Color appropriate for ethnicity|Warm|Cool|Cold|dry|clammy|diaphoretic|color appropriate for ethnicity|pale"].
[textarea name="skin" default=""][/conditional]
[checkbox name="ent" value="HEENT:"] [conditional field="ent" condition="(ent).is('HEENT:')"] [checkbox value="Normocephalic, atraumatic|PERRL|no lymphadenopathy|trachea midline|oral os without edema or erythema|no JVD"].
[textarea name="head" default=""][/conditional]
[checkbox name="rasp" value="RESP:"] [conditional field="rasp" condition="(rasp).is('RESP:')"] [checkbox value="Symmetrical with equal breath sounds. Clear to auscultation bilaterally|speaking in full sentences|diminished lung bases| wheezing|rhonchi|rales|tachypneic|nasal flaring|on RA|on supp O2 per NC|on HFNC|on mask|on BiPAP|intubated"].
[textarea name="resp" default=""][/conditional]
[checkbox name="hears" value="CARD:"] [conditional field="hears" condition="(hears).is('CARD:')"] [checkbox value="Regular rate and rhythm without murmurs, clicks or rubs|reg rate|reg rhythm|irregular rhythm|Grade I murmur best heard over apex|Grade II murmur best heard over apex|Grade III murmur best heard over apex|tachycardic|no significant abnormalities on telemetry|no significant abnormalities on 12-lead EKG|no BLE edema"].
[textarea name="card" default=""][/conditional]
[checkbox name="intest" value="GI:"] [conditional field="intest" condition="(intest).is('GI:')"] [checkbox value="Soft, non-tender and non-distended. Normal bowel sounds|soft|non-tender|non-distended|epigastric tenderness|RUQ tenderness|LUQ tenderness|RLQ tenderness|LLQ tenderness|suprapubic tenderness|right CVA tenderness|left CVA tenderness|distended|peritoneal signs present"].
[textarea name="abd" default=""][/conditional]
[checkbox name="musk" value="MS:"] [conditional field="musk" condition="(musk).is('MS:')"] [checkbox value="FROM to BUE|FROM to BLE|normal muscle bulk and tone|gait even and steady"].
[textarea name="ms" default=""][/conditional]
[checkbox name="legs" value="EXT:"] [conditional field="legs" condition="(legs).is('EXT:')"] [checkbox value="No edema to BLE, PPP, no clubbing or cyanosis|edema noted|venous stasis dermatitis to BLE|surgical extremity immobilized with sling|patient in hip precations|CMS intact to surgical extremity|surgical dressing is CDI|JP drain in place|draining sanguineous fluid|draining serous fluid|draining serosanguinous fluid|with no drainage"].
[textarea name="ext" default=""][/conditional]
[checkbox name="brains" value="NEURO:"] [conditional field="brains" condition="(brains).is('NEURO:')"] [checkbox value="Alert and oriented x 3, speech clear. No focal findings present|Alert|oriented to self|oriented to place|oriented to time|confusion noted|delirious|obtunded|somnolent|patient is at mental baseline|Cannot assess as pt is intubated"].
[textarea name="neuro" default=""][/conditional]
[checkbox name="psyche" value="PSYCH:"] [conditional field="psyche" condition="(psyche).is('PSYCH:')"] [checkbox value="Normal mood and affect|tearful|appears anxious|physically combative|verbally combative|flat affect|denies SI|endorses SI|Cannot assess as pt is intubated"].
[textarea name="psych" default=""][/conditional]

ASSESSMENT
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[textarea name="assessment" default=""]

PLAN
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[checkbox name="AdmitStatus" value="Admit the patient"] [conditional field="AdmitStatus" condition="(AdmitStatus).is('Admit the patient')"][checkbox value="to medical surgical unit|to ICU|with telemetry|in observation status|in inpatient status"].[/conditional]
[checkbox name="nurs" value="-Nursing:"] [conditional field="nurs" condition="(nurs).is('-Nursing:')"] [checkbox name="activity" value="Vital signs q4h|VS per ICU protocol|notify attending of any abnormal vitals|activity as tolerated|q4h Neurochecks|seizure precautions"]
[checkbox name="iando" value="-Strict I&O|insert/maintain foley|daily weights"]
[checkbox name="flurest" value="-Fluid restriction"]
[checkbox name="DM" value="-BG AC&HS|-BG q6hr|with LDSSI|with MDSSI|with HDSSI"]. [checkbox name="hypoglycemia" value="Hypoglycemia protocol if needed."][/conditional]
[checkbox name="lab" value="-Order additional labs:"][conditional field="lab" condition="(lab).is('-Order additional labs:')"] [checkbox name="labst" value="CBC|BMP|CMP|Trop|PCT|Mg|Phos|Lactic|BNP|BCx2|Stool studies"][text default="" size="60"][/conditional]
[checkbox name="xray" value="-Order additional image studies:"][conditional field="xray" condition="(xray).is('-Order additional image studies:')"] [checkbox name="radt" value="CXR|CT head|CT Chest|CT abd/pel|MRI Brain|MRI/MRA Brain|Carotid Duplex|Echo|Renal US"][/conditional]
[checkbox name="IVF" value="-Start IVF."][conditional field="IVF" condition="(IVF).is('-Start IVF.')"] [checkbox name="fluids" value="NS|LR|1/2 NS|D5W|D5NS|D5 1/2 NS"] [select name="rate" value="@50/hr|@75/hr|@100/hr|@125/hr|bolus 250 ml|bolus 500 ml|bolus 1000ml"] [text default="" size="60"]
[/conditional]
[checkbox name="pain" value="-Provide patient with pain control."][conditional field="pain" condition="(pain).is('-Provide patient with pain control.')"]
[checkbox name="APAP" value="-APAP"] [checkbox name="apdose" value="650 mg PO|1 gm IV"] [checkbox name="aptime" value="q4-6hr prn fever/pain. NTE 4 gm per day.|q6hr prn fever/pain. NTE 4 gm per day."]
[checkbox name="IBU" value="-IBU prn fever/pain. Monitor Cr."]
[checkbox name="ketorolac" value="-Ketorolac"] [checkbox name="kdose" value="15 mg IV|30 mg IV"] [checkbox name="ktime" value="q6hr prn pain. Monitor Cr. NTE 5 days of treatment"]
[checkbox name="hydrocodone" value="-Hydrocodone/APAP prn pain."]
[checkbox name="oxycodone" value="-Oxycodone"][checkbox name="tyl" value="/APAP"] [checkbox name="prn" value="PRN pain"]
[checkbox name="MS" value="-Morphine sulfate"] [checkbox name="msdose" value="1 mg IV|2 mg IV"] [checkbox name="mstime" value="q2h PRN pain|q4h PRN pain"]
[checkbox name="hydrom" value="-Hydromorphone"] [checkbox name="hyddose" value="0.5 mg IV|1 mg IV"] [checkbox name="hydtime" value="q2h PRN pain|q4h PRN pain"]
[checkbox name="opiodstool" value="-Monitor stools for opiate-induced constipation."]
[/conditional]
[checkbox name="nausea" value="-Provide antiemetics as needed to control nausea."][conditional field="nausea" condition="(nausea).is('-Provide antiemetics as needed to control nausea.')"]
[checkbox name="zofran" value="-Zofran IV/PO prn nausea."]
[checkbox name="Metoclopramide" value="-Metoclopramide prn nausea."]
[checkbox name="NPO" value="-Keep patient NPO for now."] [checkbox name="ADAT" value="Will advance diet as tolerated."][/conditional]
[checkbox name="bowel" value="-Start bowel regimen."][conditional field="bowel" condition="(bowel).is('-Start bowel regimen.')"] [checkbox name="miralax" value="Miralax 17gm PO q24h|Docusate 100mg PO BID|MOM 15mg PO TID|Biscodyl suppository 10mg PR x 1|Enema until clear"]
[checkbox name="repim" value="-Repeat imaging if no BM with bowel reg"][/conditional]
[checkbox name="abx" value="-Antibiotic tx:"] [conditional field="abx" condition="(abx).is('-Antibiotic tx:')"][checkbox value="Vancomycin with pharmacy to dose|pip/tazo|azithromycin|ceftriaxone|cefepime|ciprofloxacin|metronidazole|ampicillin/sulbactam|meropenem|clindamycin"]. [checkbox name="addinf" value="Follow WBC's|monitor for pyrexia|follow results of"] [checkbox name="cxtypes" value="urine cx|blood cx|wound cx|CSF cx"][/conditional]
[checkbox name="card" value="-Monitor for s/s of coronary ischemia/angina."][conditional field="card" condition="(card).is('-Monitor for s/s of coronary ischemia/angina.')"]
[checkbox name="trops" value="-Trend trops"]
[checkbox name="concard" value="-Consult cards"]
[checkbox name="hep" value="-Hep gtt per nomogram"][/conditional]
[checkbox name="homemeds" value="-Continue home meds|-Continue home meds EXCEPT for|-Hold home meds for now"] [text default="" size="30"]
[checkbox name="dailylab" value="-Trend daily labs"]
[checkbox name="kreplace" value="-Trend and correct any electrolyte imbalances"]
[checkbox name="monitorcr" value="-Monitor Cr."][conditional field="monitorcr" condition="(monitorcr).is('-Monitor Cr.')"] [text default="Baseline creat is" size="30"][/conditional] 

[textarea name="Plan" default=""]

[checkbox name="Problem444" value="Code Status:"][conditional field="Problem444" condition="(Problem444).is('Code Status:')"] [checkbox name="CODE" value="FULL|DNR"][/conditional]

[checkbox name="Problem445" value="Consult:"][conditional field="Problem445" condition="(Problem445).is('Consult:')"] [checkbox name="CONSULT" value="Cardiology|Ortho|Gen Surgery|Neurology|Podiatry|Dietary|RT|ST|OT|PT|CM"] [textarea name="Consult" default=""][/conditional]

[checkbox name="Problem665" value="VTE RISK ASSESSMENT"] 
[conditional field="Problem665" condition="(Problem665).is('VTE RISK ASSESSMENT')"]
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Padua Prediction Score for Risk of VTE 

1. Active Cancer?
[select name="cancer" value="No=0|Yes=3"]
2. Previous VTE?
[select name="VTE" value="No=0|Yes=3"]
3. Reduced Mobility?
[select name="mobility" value="No=0|Yes=3"]
4. Already known thrombophilic condition?
[select name="thrombophilic" value="No=0|Yes=3"]
5. Recent (≤1 month trauma and/or surgery)?
[select name="surgery" value="No=0|Yes=2"]
6. Elderly age (≥70 years)?
[select name="elderly" value="No=0|Yes=1"]
7. Heart and/or respiratory failure?
[select name="failure" value="No=0|Yes=1"]
8. Acute MI and/or ischemic stroke?
[select name="stroke" value="No=0|Yes=1"]
9. Acute infection and/or rheumatologic disorder?
[select name="infection" value="No=0|Yes=1"]
10. BMI >30?
[select name="BMI" value="No=0|Yes=1"]
11. Ongoing hormonal treatment?
[select name="hormonal" value="No=0|Yes=1"]
....................................................................................
Total score: [calc value="(cancer)+(VTE)+(mobility)+(thrombophilic)+(surgery)+(failure)+(stroke)+(infection)+(BMI)+(hormonal)" memo="score"] (maximum=20)

[select name="variable_1" value="Score less than 4: Low risk for VTE. Pharmacologic prophylaxis is not indicated. Use mechanical prophylaxis.|Score of 4 or more: Pharmacologic Prophylaxis is indicated. If high risk of bleeding, use mechanical prophylaxis."][/conditional]

PROPHYLAXIS
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VTE Prophylaxis: [checkbox name="dvtppe" value="Early ambulation|SCDs|Lovenox|Heparin|Warfarin|NOAC|Pharmacologic prophylaxis contraindicated due to"] [textarea name="contraindicated" default=""]

Stress Ulcer Prophylaxis: 
Risk Factors Include: [checkbox name="gippx" value="probable mechanical ventilation for more than 48 hours|coagulopathy (INR over 1.5, platelets less than 50)|past history of gastric ulcer or GI bleeding in past 12 months|recent trauma (TBI, spinal cord injury,burns)|greater than 1 week in the ICU|occult GI bleeding|high dose steroid treatment|No risk factors"].
[select value="Stress ulcer prophylaxis not indicated|H2RA ordered|PPI ordered|Patients home medication restarted"].

DISPOSITION PLANNING/COORDINATION OF CARE
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Dispo: Patient with likely hospitalization for [text size="80"]

[comment memo="Family Communication"]
[checkbox name="Problem2" value="Patient and Family Communication:"][conditional field="Problem2" condition="(Problem2).is('Patient and Family Communication:')"] 
[checkbox name="Problem20" value="Spoke at bedside|Spoke via telephone"] with [select name="variable_1" value="spouse of|mother of|father of|child of|DPOA of"] patient regarding [checkbox name="Problem21" value="current treatment plan|change in condition|results of testing"]. They [checkbox name="Problem22" value="are able to ask questions|verbalize concerns|and state an agreement with the current plan|and request that"] [textarea name="variable_100" default=""].
[/conditional]
[comment memo="PCP or Specialist Communication"]
[checkbox name="Problem3" value="Primary Care/Specialist Communication:"][conditional field="Problem3" condition="(Problem3).is('Primary Care/Specialist Communication:')"] 
Spoke with [select name="variable_200" value="specialist|primary care provider"] [text name="variable_202" default=""][select name="variable_201" value=", MD|, DO|, NP|, PA"] [checkbox name="variable_208" value="with cardiology|with general surgery|with orthopedics|with podiatry|with ID|with neuro|with nephro|with urology|with HIV med clinic|with OBGYN"] regarding patients [checkbox name="variable_204" value="admission|hospital course|disposition|death"]. [checkbox name="variable_205" value="Verbalizes understanding and agrees with plan|makes the following recommendations:"] [textarea name="variable_206" default=""].[/conditional]
[comment memo="Case Management Communication"]
[checkbox name="case" value="Case Management:"][conditional field="case" condition="(case).is('Case Management:')"] 
[checkbox name="cmplan" value="Discussed plan of care with case management."] 
[checkbox name="cmdisc" value="Planned discharge to home|Planned discharge to swing bed program|Planned discharge to inpt rehab|Planned discharge to SNF|with home health|with hospice"]. [checkbox name="mcplanfam" value="Patient and caregiver has been involved in this decision-making and agrees with plan."] 
[checkbox name="dme" value="Patient will have DME needs upon discharge. Case management is assisting with this. Needs will include:|wheelchair|walker|cane|orthotic device|home oxygen|home IV antibiotic therapy|Patient will not have any DME needs upon discharge"] 
[checkbox name="seecmnote" value="Please see CM notes for additional information."] 
[/conditional]

COMMUNICATION WITH ATTENDING PHYSICIAN
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Admit H&P completed by NP/PA. Admit plan discussed with attending physician [checkbox value="Elisha Yaghmai, MD|Hannah Bingham, MD|Aaron Olson, MD|Kristen Cline, MD|Manish Shah, MD"] who agrees with plan.