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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.
Return indications and follow up instructions reviewed with patient who is agreeable with plan. See DCI.





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Return indications and follow up instructions reviewed with patient who is agreeable with plan. See DCI.

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