SBA Complete ED Note

[text name="Name" default="Patient Name"]

HPI and health hx collected from: [checkbox name="Presenting Info" value="from patient|from family|from EMS|from nursing staff"].

Patient arrives via [checkbox name="arrival" value="POV|EMS|law enforcement"]

[textarea name="HPI" default="HPI"]

[checkbox name="Problem21" value="Patient denies"] [conditional field="Problem21" condition="(Problem21).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]

Please see HPI for additional ROS.

[select name="variable_1" memo="<--- Select Exam" value="General Adult Exam|General Male Exam|General Female Exam"]
[textarea name="variable_2" cols=80 rows=2 default="GENERAL APPEARANCE: Well developed, well nourished, alert and cooperative, and appears to be in no acute distress."]
[textarea name="variable_3" cols=80 rows=1 default="HEAD: normocephalic."]
[textarea name="variable_4" cols=80 rows=1 default="EYES: PERRL, EOMI. Fundi normal, vision is grossly intact."]
[textarea name="variable_5" cols=80 rows=1 default="EARS: External auditory canals and tympanic membranes clear, hearing grossly intact."]
[textarea name="variable_6" cols=80 rows=1 default="NOSE: No nasal discharge."]
[textarea name="variable_7" cols=80 rows=2 default="THROAT: Oral cavity and pharynx normal. No inflammation, swelling, exudate, or lesions. Teeth and gingiva in good general condition."]
[textarea name="variable_8" cols=80 rows=1 default="NECK: Neck supple, non-tender without lymphadenopathy, masses or thyromegaly."]
[textarea name="variable_9" cols=80 rows=3 default="CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is regular. There is no peripheral edema, cyanosis or pallor. Extremities are warm and well perfused. Capillary refill is less than 2 seconds. No carotid bruits."]
[textarea name="variable_10" cols=80 rows=2 default="LUNGS: Clear to auscultation and percussion without rales, rhonchi, wheezing or diminished breath sounds."]
[textarea name="variable_11" cols=80 rows=2 default="ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender. No guarding or rebound. No masses."]
[textarea name="variable_12" cols=80 rows=2 default="MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and extremities. No joint erythema or tenderness. Normal muscular development. Normal gait."]
[textarea name="variable_13" cols=80 rows=2 default="BACK: Examination of the spine reveals normal gait and posture, no spinal deformity, symmetry of spinal muscles, without tenderness, decreased range of motion or muscular spasm."]
[textarea name="variable_14" cols=80 rows=2 default="EXTREMITIES: No significant deformity or joint abnormality. No edema. Peripheral pulses intact. No varicosities."]
[textarea name="variable_15" cols=80 rows=5 default="LOWER EXTREMITY: Examination of both feet reveals all toes to be normal in size and symmetry, normal range of motion, normal sensation with distal capillary filling of less than 2 seconds without tenderness, swelling, discoloration, nodules, weakness or deformity; examination of both ankles, knees, legs, and hips reveals normal range of motion, normal sensation without tenderness, swelling, discoloration, crepitus, weakness or deformity."]
[textarea name="variable_16" cols=80 rows=2 default="NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout. Cerebellar testing normal."]
[textarea name="variable_17" cols=80 rows=1 default="SKIN: Skin normal color, texture and turgor with no lesions or eruptions."]
[textarea name="variable_18" cols=80 rows=3 default="PSYCHIATRIC: The mental examination revealed the patient was oriented to person, place, and time. The patient was able to demonstrate good judgement and reason, without hallucinations, abnormal affect or abnormal behaviors during the examination. Patient is not suicidal."][conditional field="variable_1" condition="(variable_1).is('General Male Exam')"][textarea name="variable_19" cols=80 rows=2 default="RECTAL: Good sphincter tone with no anal, perineal or rectal lesions. Prostate is not tender, enlarged, boggy, or nodular."][/conditional]
[conditional field="variable_1" condition="(variable_1).is('General Male Exam')"][textarea name="variable_20" cols=80 rows=3 default="GENITALIA: Genital exam revealed normally developed male genitalia. No scrotal mass or tenderness, no hernias or inquinal lymphadenopathy. No perineal or perianal abnormalities are seen. No genital lesions or urethral discharge."][/conditional][conditional field="variable_1" condition="(variable_1).is('General Female Exam')"][textarea name="variable_21" cols=80 rows=1 default="BREASTS: No masses, tenderness, asymmetry, nipple discharge or axillary lymphadenopathy."][/conditional]
[conditional field="variable_1" condition="(variable_1).is('General Female Exam')"][textarea name="variable_22" cols=80 rows=3 default="PELVIC: Normally developed external female genitalia with no external lesions or eruptions. Vagina and cervix have no lesions, inflammation, discharge or tenderness. Cervix is nontender. Uterus is within normal limits with no adnexal fullness."][/conditional]

[checkbox name="Problem1" value="ED Course: All information reviewed."] [conditional field="Problem1" condition="(Problem1).is('ED Course: All information reviewed.')"] [checkbox name="Problem2" value="Chest X-Ray shows"] [conditional field="Problem2" condition="(Problem2).is('Chest X-Ray shows')"][checkbox value="no abnormalities,|infiltrates/findings indicative of PNA,|effusion of the ***,|cardiomegaly,|pulmonary edema,"] [checkbox name="Problem3" value="CBC-"] [conditional field="Problem3" condition="(Problem3).is('CBC')"][checkbox value="unremarkable,|leukocytosis,|anemia,|low platelets,|bandemia,"] [checkbox name="Problem4" value="Chemistry-"] [conditional field="Problem4" condition="(Problem3).is('Chemistry-')"][checkbox value="unremarkable,|hyponatremia,|hypernatremia,|hypokalemia,|hyperkalemia,|HAGMA,|elevated BUN,|elevated Cr,|hypomagnesmia,"] [checkbox name="Problem7" value="UA-"] [conditional field="Problem7" condition="(Problem7).is('UA-')"][checkbox value="without s/s of infection,|positive leukocytes,|positive nitrates,|positive protein,|positive glucose,|positive ketones,"] [checkbox name="Problem5" value="Troponin-"] [conditional field="Problem5" condition="(Problem5).is('Troponin-')"][checkbox value="negative,|elevated,"] [checkbox name="Problem6" value="D-Dimer-"] [conditional field="Problem6" condition="(Problem6).is('D-Dimer-')"][checkbox value="negative,|elevated,"].[/conditional]

[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|tachycardia|bradycardia|normal axis|left axis deviation|right axis deviation|PR interval normal|QRS complex normal|No relevant ST segment deviation/elevation in contiguous leads|QT interval not prolonged"] [text size="80"][/conditional]

During ED course [checkbox name="Disposition Condition" value="patient with improvement in symptoms|patient stabilized|pt condition worsens"].

[checkbox name="dispo" value="Patient will be admitted for further management and diagnostics|Patient will be discharged back to SNF/AL|Pt will be discharged to home|Pt offered admission for further management and refuses. Extensive time spent discussing potential of poor outcomes by refusing admission. Pt verbalizes understanding and continues to refuse admission at this time|Pt leaves AMA"].

[checkbox name="consults" value="Elisha Yaghmai,MD|Hannah Bingham,MD|Aaron Olson,MD|Kristen Cline, MD|General Surgery|Cardiology|***"]

[checkbox name="dispo_home" value="Strict return precautions discussed with patient. Education regarding s/s of worsening or returning condition discussed. Patient verbalizes understanding of returning immediately with any concerns. Reports understanding of following up as directed and taking all prescriptions and treatments as directed."]

For a list of discharge medications, follow up appointments, and patient education/instructions, please see the "Discharge Instructions" document in the EHR.

HPI and health hx collected from: .

Patient arrives via

Please see HPI for additional ROS.

<--- Select Exam

During ED course .



For a list of discharge medications, follow up appointments, and patient education/instructions, please see the "Discharge Instructions" document in the EHR.

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