ED Note SBA

[comment memo="HPI"]
Patient is a [text size="3" ]-year-old [select value="male|female"] that arrives via [select value="EMS|POV|ambulatory|in wheelchair|via stretcher|carried by guardian"] who being seen in the emergency department with a presenting complaint of [textarea name="hpi" default=""].

[select value="Patient|Guardian|Family member who is with patent|EMS crew"] reports that this [select value="started|occurred"] [text size="3"] [select value="minutes ago|hours ago|days ago|weeks ago|months ago|immediately PTA"].

[checkbox name="pain" value="Pain is described as"] [conditional field="pain" condition="(pain).is('Pain is described as')"][checkbox value="sharp|dull|stabbing|pressure|squeezing|aching|burning|tearing|ripping|without radiation|without radiation"]. [textarea name="paindec" default=""]

[checkbox value="Patient denies any history of these symptoms in the past.|Patient reports having similar symptoms in the past."] 
[textarea name="paintxt" default=""][/conditional] 

[checkbox value="Patient has not attempted to treat these symptoms at home.|Patient has attempted to treat these symptoms at home including the use of"] [checkbox value="OTC APAP|OTC IBU|antihistamines|antacids|rest|heat|ice|massage|elevation"]. [checkbox value="These measures were not effective.|These measures were somewhat effective.|These measures were effective."] [textarea name="hometx" default=""]
[checkbox value="Patient denies any factors that make the symptoms better or worse."]

[checkbox name="aggravating" value="The patient reports that the following factors make symptoms worse:"] [conditional field="aggravating" condition="(aggravating).is('The patient reports that the following factors make symptoms worse:')"][checkbox value="movement|eating or drinking|exertion|laying flat|pressure on the affected area|bending|standing|twisting]. [textarea name="agg" default=""][/conditional]

[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="Problem400" value="GENERAL:"] [conditional field="Problem400" condition="(Problem400).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="Problem401" value="SKIN:"] [conditional field="Problem401" condition="(Problem401).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="Problem402" value="HEENT:"] [conditional field="Problem402" condition="(Problem402).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="Problem403" value="RESP:"] [conditional field="Problem403" condition="(Problem403).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="Problem404" value="CARD:"] [conditional field="Problem404" condition="(Problem404).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="Problem405" value="GI/GU:"] [conditional field="Problem405" condition="(Problem405).is('GI/GU:')"] [checkbox value="Soft, non-tender and non-distended. Normal bowel sounds|soft|non-tender|non-distended|bowel sounds normal|bowel sounds hypoactive|bowel sounds hyperactive|bowel sounds absent|epigastric tenderness|RUQ tenderness|LUQ tenderness|RLQ tenderness|LLQ tenderness|suprapubic tenderness|right CVA tenderness|left CVA tenderness|distended|peritoneal signs present|foley catheter in place"]. [textarea name="abd" default=""][/conditional]

[checkbox name="Problem406" value="MS:"] [conditional field="Problem406" condition="(Problem406).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="Problem407" value="EXT:"] [conditional field="Problem407" condition="(Problem407).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="Problem408" value="NEURO:"] [conditional field="Problem408" condition="(Problem408).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="Problem409" value="PSYCH:"] [conditional field="Problem409" condition="(Problem409).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]

[checkbox name="Problem410" value="GCS Score:"] [conditional field="Problem410" condition="(Problem410).is('GCS Score:')"] Glasgow Coma Scale (GCS)
.....................................................................................................
1. Best Eye Opening Response
[select name="eye" value="Spontaneous (4 points)=4|Opens to verbal command (3 point)=3|Eyes open to pain (2 points)=2|No eye opening (0 points)=0"]

2. Verbal Response
[select name="verbal" value="Oriented (5 points)=5|Confused but answering questions (4 point)=4|Inappropriate response, words discernible (3 points)=3|Incomprehensible sounds or speech (2 points)=2|No verbal response (1 point)=1"]

3. Motor Response
[select name="motor" value="Obeys commands (6 points)=6|Purposeful movement to painful stimuli (5 points)=5|Withdraws from pain (4 points)=4|Abnormal flexion (decorticate) (3 points)=3|Abnormal extension (decerberate)(2 points)=2|No motor response (1 point)=1"]
.....................................................................................................
Total score: [calc value="(eye)+(verbal)+(motor)" memo="score"] (maximum=15)
[/conditional] 
[checkbox name="Problem411" value="NIH Score:"] [conditional field="Problem411" condition="(Problem411).is('NIH Score:')"] National Institutes of Health (NIH) Stroke Scale
.....................................................................................................
1a. Assess Level of Consciousness (Alert=0, Coma=3)
[select name="conscious" value="Alert (0 points)=0|Not Alert; arousable by minor stimulation (1 point)=1|Not alert; requires repeated stimulation to attend (2 points)=2|Not responsive or reflexive posturing only (3 points)=3"]

1b. Assess Orientation: Month, Age (1 point per bad answer)
[select name="orientation" value="Answers both questions correctly (0 points)=0|Answers one question correctly (1 point)=1|Answers neither question correctly (2 points)=2"]

1c. Follow Commands: Open and close eyes, make fist and release (1 point per command NOT obeyed)
[select name="commands" value="Performs both tasks correctly (0 points)=0|Performs one task correctly (1 point)=1|Performs neither task correctly (2 points)=2"]

2. Follow my finger (Normal=0, Forced deviation=2)
[select name="finger" value="Normal (0 points)=0|Partial gaze palsy (1 point)=1|Forced deviation (2 points)=2"]

3. Visual field (Normal=0, hemianopia=2, bilateral loss=3)
[select name="visual" value="No visual loss (0 points)=0|Partial hemianopia (1 point)=1|Complete hemianopia (2 points)=2|Bilateral loss (3 points)=3"]

4. Facial palsy: Show teeth, Raise eyebrows, Squeeze eyes shut (Normal=0, Complete=3)
[select name="face" value="Normal (0 points)=0|Minor paralysis (1 point)=1|Partial paralysis (2 points)=2|Complete paralysis (3 points)=3"]

5a. Motor Strength Left Arm: Elevate to 90 degrees
[select name="left_arm" value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]

5b. Motor Strength Right Arm: Elevate to 90 degrees
[select name="right_arm" value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]

6a. Motor Strength Left Leg: Elevate to 30 degrees
[select name="left_leg" value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]

6b. Motor Strength Right Leg: Elevate to 30 degrees
[select name="right_leg" value="No drift (0 points)=0|Drift (1 point)=1|Some effort against gravity (2 points)=2|No effort against gravity (3 points)=3|No movement (4 points)=4|Amputation or joint fusion (0 points)=0"]

7. Coordination or limb ataxia: Finger-nose-finger, Heel-knee-shin (Absent=0, both limbs=2)
[select name="ataxia" value="Absent (0 points)=0|Ataxia in one limb (1 point)=1|Ataxia in two limbs (2 points)=2"]

8. Sensory: Pin prick to face, arm, trunk, and legs, Compare sides (Normal=0, Severe loss=2)
[select name="sensory" value="Normal (0 points)=0|Mild to moderate loss (1 point)=1|Severe to total loss (2 points)=2"]

9. Language: Name items, Describe picture, Read sentences (No Aphasia=0, Mute=3)
[select name="language" value="No aphasia (0 points)=0|Mild to moderate aphasia (1 point)=1|Severe aphasia (2 points)=2|Mute, global aphasia (3 points)=3"]

10. Dysarthria: Speech clarity while reading word list (Normal=0, Nearly unintelligible=2)
[select name="dysarthria" value="Normal (0 points)=0|Mild to moderate dysarthria (1 point)=1|Severe dysarthria (2 points)=2|Intubated or physical barrier (0 points)=0"]

11. Extinction and Inattention: Formerly called 'Neglect' (None=0, Complete=2)
[select name="extinction" value="No abnormality (0 points)=0|Visual, tactile, auditory, spatial, or personal inattention in one sensory modality (1 point)=1|Profound hemi-inattention or extinction to more than one modality (2 points)=2"]

.....................................................................................................
Total score: [calc value="(conscious)+(orientation)+(commands)+(finger)+(visual)+(face)+(left_arm)+(right_arm)+(left_leg)+(right_leg)+(ataxia)+(sensory)+(language)+(dysarthria)+(extinction)" memo="score"] (maximum=42)
[/conditional]

[comment memo="ED LABS AND DIAGNOSTICS"][checkbox name="Problem1" value="Vital signs, labs, diagnostics, and nursing documentation reviewed."]

[comment memo="ED IMAGING"][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="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|with s/s of infection|positive leukocytes|positive nitrates|positive protein|positive glucose|positive ketones|positive WBCs|+ 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]