ED SBA Dispo

Initial Impression:
[text size="80"]

DDx:
[text name="dx" default="Differential diagnoses include:

These are less likely given the clinical and diagnostic findings present during this emergency department visit."]

After review of clinical data, the likelihood of a life-threatening illness is ruled out reasonably enough to safely discharge to home., Patient residing in a facility with appropriate monitoring by staff/caregivers that allows for return to facility., Patient's clinical condition warrants further treatment/differentiation on an inpatient setting to assure appropriate monitoring and safety.

Patient will be admitted to SBA for further management., Patient offered admission to SBA but refusing at this time., The patient has decided to leave against medical advice. They have normal mental status and adequate capacity to make medical decisions. The patient refuses hospital admission and wants to be discharged. The risks have been explained to the patient, including _________, worsening illness, chronic pain, permanent disability and death. The benefits of admission have also been explained, including the availability and proximity of nurses, physicians, monitoring, diagnostic testing, treatment and ___________. The patient was able to understand and state the risks and benefits of hospital admission. They had the opportunity to ask questions about their medical condition. The patient was treated to the extent that they would allow and knows that they may return for care at any time. The patient has been encouraged to arrange follow up.

Patient is provided with both verbal and written discharge instructions. The patient is given the opportunity to ask questions and address concerns. Pt verbalizes understanding of current condition and need to return immediately for any worsening or change in condition. Patient is educated on the importance of PCP follow up and of routine care for overall health, Patient leaves AMA without receiving full discharge education or instructions despite being encouraged to stay for additional testing/education, Patient educated on the need for further diagnostics/monitoring and agrees to admission.

I have seen and treated this patient independently consistent with my level of credentialing and licensure., I have spoken with the attending physician who agrees with my current plan of care.

Portions of this chart may have been generated using voice recognition software which does not employ spell checking or grammar checking features.  It was dictated in a noisy patient care environment.  The dictation may contain unrecognized and wholly unintended errors or omissions.

This emergency department visit is of straight-forward, low, moderate, high complexity

Data reviewed includes ordering and reviewing of lab testing, ordering and reviewing of radiology testing, consultation with PCP/specialty physician, visualization of 12-lead ECG

Risk of complications is low, requiring only OTC medication or acute uncomplicated illness/injury, moderate, with systemic symptoms and complications such as an acute, complicated injury, or exacerbation of chronic disease, high, with abrupt neuro changes, life threatening illness, severe exacerbation of chronic illness, parenteral controlled medications or medications requiring close monitoring being present

Critical care time was provided of 30-74 minutes, 75-104 minutes, 105-134 minutes