CRITICAL CARE TELEMEDICINE NOTE

CRITICAL CARE TELEMEDICINE [select name="variable_01b" value="xxx|CONSULT|PROGRESS"] NOTE 
DATE OF SERVICE:  [date name="variable_01"]; TIME OF ENCOUNTER:  [select name="variable_zzzz" value="00|01|02|03|04|05|06|07|08|09|10|11|12|13|14|15|16|17|18|19|20|21|22|23"][select name="variable_zzzz2" value="00|05|10|15|20|25|30|35|40|45|50|55"] hrs

[select name="variable_01a" value="xxx|HISTORY OF PRESENT ILLNESS|UPDATES"]:  [textarea name="variable_02" default=""]

PAST MEDICAL HISTORY:  Reviewed in the EMR.  All pertinent history is listed above in the HPI or UPDATES section.

REVIEW OF SYSTEMS:  All findings in the 12-point ROS were negative except for what is stated above in the HPI or UPDATES section.

ADVERSE DRUG REACTIONS:  Reviewed in the EMR.  All pertinent reactions are listed above in the HPI or UPDATES section.

HOME MED LIST:  Reviewed in the EMR.  All pertinent meds are listed above in the HPI or UPDATES section.  
CHART DATA & FLOW SHEET DATA:  Reviewed in the EMR.  All pertinent values are listed above in the HPI or UPDATES section.  

TELEMEDICINE EXAM PERFORMED AT [select name="variable_03" value="00|01|02|03|04|05|06|07|08|09|10|11|12|13|14|15|16|17|18|19|20|21|22|23"][select name="variable_04" value="00|05|10|15|20|25|30|35|40|45|50|55"] HRS TODAY
GENERAL: [checkbox name="variable_05" value="alert|calm|agitated|obtunded|lethargic|sedated|somnolent|resp status is fair|work of breathing is fair|work of breathing is high|not in distress|in distress"][text name="variable_33" default=",    "]
LUNGS:  [checkbox name="variable_06" value="RN reports clear breath sounds bilaterally, no adventitious breath sounds.  I observe symmetrical chest rise, no obvious accessory muscle use, and stable work of breathing|work of breathing is fair|work of breathing is high|in sync with vent|on BiPAP|on heated/humidified HFNC|wheeze|rales|rhonchi"][text name="variable_34" default=",    "]
HEART:   [checkbox name="variable_07" value="RN reports a regular strong periph pulse, no murmurs or other abnormal sounds, and normal peripheral cap refill|sinus|afib|tachycardic|bradycardic|normal rate|periph pulse strong|periph pulses weak"][text name="variable_35" default=",    "]
GI:   [checkbox name="variable_08" value="RN reports abd to be soft with no tenderness, distention, rebound, or guarding|tender|distended"][text name="variable_36" default=",    "]
EXTREMITIES:   [checkbox name="variable_09" value="I note no trauma, or deformities.  RN reports no edema and warm extremities x 4.|anasarcic|+ LE edema"][text name="variable_37" default=",    "]
NEURO:   [checkbox name="variable_10" value="no obvious gross focal neuro abnormalities seen on video|sedated|"][text name="variable_38" default=",    "]
SKIN:   [checkbox name="variable_11" value="no peripheral cyanosis, pallor, or lesions seen on video"][text name="variable_39" default=",    "]
MSE:   [checkbox name="variable_12" value="awake, alert, oriented, and appropriate|sedated|obtunded|lethargic|somnolent|agitated|anxious"][text name="variable_40" default=",    "]

CRITICAL PROBLEM LIST
[textarea name="variable_13" default="1. "]

RESPIRATORY:  [textarea name="variable_14" default=""]

INFECTIOUS DISEASE:  [textarea name="variable_15" default=""]

CARDIOVASCULAR:  [textarea name="variable_16" default=""]

HEMATOLOGY:  [textarea name="variable_17" default=""]

METABOLIC / RENAL:  [textarea name="variable_18" default=""]

GI / BILIARY / NUTRITION:  [textarea name="variable_19" default=""]

NEUROLOGY:  [textarea name="variable_20 default=""]

INVASIVE DEVICES:[textarea name="variable_21" default=""]

[x] [checkbox name="variable_99" value="consent for telemed encounter obtained & documented by bedside team prior to this note|consent for telemed encounter cannot be obtained as no decision-makers are immediately available, & given the patient's critical illness, the patient lacks capacity to provide it.  The provider of record & I deem the consultation to be necessary because the patient is critically ill & at risk of life threatening deterioration."]
[x] I spent [select name="variable_99" value="xxx|60|50|70|35"] min managing patient's critical illness
[x] the entirety of this encounter was done via telemedicine
[x] during the eval, the pt was in their hospital room 
[x] during the eval, I was in an off-site secure private office
[x] HIPAA-compliant live real-time 2-way video was used for the telemed exam 
[x] an RN was assisting at the bedside during the telemed exam
[x] I REVIEWED PMH, HOME MEDS, ADVERSE MED REACTIONS, AND ROS FROM TEAM & CHART
[x] I REVIEWED LABS, RADIOLOGY, FLOWSHEETS, & INPATIENT MEDS FROM CHART
[x] ALL PERTINENT FINDINGS ARE INCLUDED IN THE HPI/UPDATES SECTIONS ABOVE
[x] all recommendations are based on a telemedicine consult request
[x] all patient care and treatment decisions are ultimately deferred to the hospital-based provider using their own independent medical judgment

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