codesfill

Return indications and follow up instructions reviewed with patient who is agreeable with plan. See DCI. 
[select name="Q1" value="Code Stroke Activated|Patient BIBA after cardiac arrest with ROSC|Pregnant vag bleed|Code Sepsis"]
[conditional field="Q1" condition="(Q1).is('Code Stroke Activated')"]
[textarea default="Patient's LKWT was  "] 
[textarea default="NIHSS is "]
[textarea default="Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others."]
[checkbox name="variable_1" value="EKG, CXR and labs obtained and patient was brought emergently to CT."]
[textarea default="Pt's presentation and findings discussed initially with neurologist on call, Dr. ** who recommended "]
[textarea default="CT/CTA showed: ** Neurologist updated with results and now recommends ** "]
[checkbox name="variable_1" value="ASA administered"]
[textarea default="Patient is within the 4.5 hr window for tPA, meets all inclusion criteria and no exclusion criteria identified."]
[checkbox name="variable_2" value="Risks and benefits of tPA were discussed with patient and/or family who have given informed consent for treatment|Risks and benefits of tPA were discussed with patient and/or family who at this time decline treatment.|tPA administered|The patient will be admitted to the hospital to ICU for further workup and treatment.|The patient will be transferred for higher level of care for possible interventional directed clot retrieval."]
[textarea default="Discussed with "][comment memo="timestamp"]

[/conditional]
[conditional field="Q1" condition="(Q1).is('Patient BIBA after cardiac arrest with ROSC')"]
[comment memo="Please note the following: Calculate the total downtime which may be from last known well to ROSC, or if witnessed - time of arrest to time of ROSC - note time EMS arrived, note time ACLS was started"]
[textarea default="EMS was called for"]
[textarea default="ON EMS arrival, patient found to be "][comment memo="pulseless, apneic, initial rhythm on the monitor was "]
[textarea name="variable_4" default="LKWT/Witnessed arrest time was: "]
[textarea name="variable_2" default="ACLS measures were started at: "]
EMS performed the following interventions prior to arrival [checkbox name="variable_1" value="Patient was intubated|Patient was bagged with BVM en route|IO was placed|IV placed|Patient was shocked one or more times|ACLS per protocol"]
Timestamps: [textarea name="variable_3" default="ROSC achieved at: Lost pulses again at, etc."]
[textarea default="Total down time without CPR: **. Total downtime with CPR: **"]
[textarea default="Other pertinent historical history"]
Emergency Caveat: Further history and physical precluded by [checkbox name="variable_1" value="patient acuity|unresponsive|pt intubated|in cardiac arrest"]
[textarea default="Discussed with "]

[/conditional]
[conditional field="Q1" condition="(Q1).is('Pregnant vag bleed')"]
[textarea]This patient in the first trimester of pregnancy presented to the emergency department with complaints of vaginal bleeding and abdominal pain. VSS. Os is closed.[/textarea]

A pelvic ultrasound demonstrated [select value="normal intrauterine gestation with normal FHT.|failure to identify a gestational sac.|blighted ovum.|subchorionic hemorrhage."] Rh was [checkbox value="positive.|negative and patient administered Microrogham."] UA was [checkbox value="positive|negative"] for infection. 

Clinical Impression: [select value="Threatened Miscarriage|UTI|Early Pregnancy vs. Ectopic|Missed Abortion"] [text] 
Anticipatory guidance, supportive measures and return indications discussed with patient. See DCI.


DCI:
Bed rest. Pelvic Rest.
Drink plenty of fluids. 
[checkbox value="Take the antibiotics prescribed for urinary tract infection|Follow up with your OB/GYN in 1-2 days|Return here or with your OB in 48 hours for repeat BHCG level|Bring a copy of your results from today's visit"] 
Return to the ER for increased bleeding (more than 1 pad an hour for consecutive hours), increased abdominal cramping, fever, passage of products of conception, lightheadedness or any other concerns.

[/conditional][conditional field="Q1" condition="(Q1).is('Code Sepsis')"][comment memo="SIRS CRITERIA: 2 or more (note which ones): T>100.9F or < 96.8F, HR>90 bpm, RR>20/min, WBC count > 12,000 or < 4000 or >10%bands"]
[textarea default="Patient has 2 or more SIRS criteria and potential source of infection, therefore initial screening labs were drawn and sent including cultures and lactate."]
[comment memo="END ORGAN DYSFUNCTION: LACTATE >2 OR SBP <90 or MAP <65, AMS, bili>2, PLatelet count < 100, creatinine >2, new Hypoxemia. (Document code sepsis criteria.)"]
[textarea default="INITIAL LACTATE was ***.  CODE SEPSIS ACTIVATED at ***."]   [comment memo="timestamp"]
[comment memo="3 hour bundle goals"]
[checkbox name="variable_12" value="Bundle was initiated and lactate was drawn|Cultures obtained|Broad spectrum antibiotics ordered|30 cc/kg IVF bolus administered."]
[comment memo="6 hour bundle goals"]
[checkbox name="variable_13" value="Patient is persistently hypotensive after 30 cc/kg bolus|Rationale for and Informed consent obtained for central line| Central line placed - see procedure note|Norepinephrine started"]
[textarea default="REPEAT LACTATE was ***."] [comment memo="Other response to interventions and timestamped discussions with consultants."]
[textarea name="variable_1" default="SEPSIS REASSESSMENT PERFORMED AT:"] [comment memo="timestamp - delete if not performed"]
[/conditional]

[frontload soapnote="sample/test"]
Return indications and follow up instructions reviewed with patient who is agreeable with plan. See DCI.