ED Course test
[checkbox name="Q1" value="Code Stroke|Patient BIBA after cardiac arrest with ROSC|Pregnant vag bleed|Code Sepsis|ED Course"] [conditional field="Q1" condition="(Q1).is('Code Stroke')"] [textarea columns=80 rows=25 fillable="true"]******Patient presented with signs and symptoms concerning for stroke. ******Differential diagnosis includes ischemic stroke, hemorrhagic stroke, todd's paralysis, hypoglycemia, brain mass, metabolic encephalopathy, among others. Patient's blood sugar was ******. Patient's LKWT was ******. ***Timestamp*** Code Stroke Activated. Patient's initial NIHSS was ******. ******EKG, CXR and labs obtained and patient was brought emergently to CT. ***Timestamp*** Pt's presentation and findings discussed initially with neurologist on call, Dr. ****** who recommended ******. ***Timestamp*** CT/CTA showed: ******. Neurologist updated with results and now recommends ******.[/textarea] [checkbox name="variable_3" value="Patient is within the 4.5 hr window for tPA, meets all inclusion criteria and no exclusion criteria identified.|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.|ASA administered.|The patient will be admitted to stroke - tele 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] [textarea default="ON EMS arrival, patient found to be "][comment memo="pulseless, apneic, initial rhythm on the monitor was "][/textarea] [textarea name="variable_4" default="LKWT/Witnessed arrest time was: "][/textarea] [textarea name="variable_2" default="ACLS measures were started at: "][/textarea] 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"] ED COURSE [textarea columns=80 rows=15 fillable="true"]***Timestamp time of arrival*** Patient brought in by EMS in cardiac arrest. ***LKWT*** Initial rhythm was ******. ******Ddx includes but not limited to ******. ***Workup initiated***. ***CPR continued***. [/textarea] [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] [conditional field="Q1" condition="(Q1).is('ED Course')"] [comment memo="Prompt your provider add in the details like age of patient and pertinent PMHx. Note abnormal vital signs and pertinent physical exam findings. Ddx includes but not limited to"] [textarea name="variable_1" default="ASSESSMENT:"] [link memo="Ddx" url="https://www.soapnote.org/miscellaneous/mdm-master-2/"] ED COURSE [text name="variable_1" default="Timestamp"] [checkbox name="variable_1" value="Patient evaluated at bedside. Orders placed. Will reassess pending|EKG|XRAYS|LABS|CT|US|MEDICATIONS"] [comment memo="Patient reassessed, Family now at bedside, Prior records reviewed, Procedure performed - see Procedure note, Discussed with"] [textarea name="variable_16" default=""] [checkbox name="variable_2" value="Results and diagnostic impression reviewed with patient who expresses understanding. Return indications and follow up instructions reviewed with patient in detail and patient acknowledges.|Results and plan for admission discussed with patient who is on board."] [textarea name="variable_3" default=""] [/conditional]
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Sandbox Metrics: Structured Data Index 0.4, 47 form elements, 2 text boxes, 16 text areas, 10 checkboxes, 2 drop downs, 1 links, 11 comments, 5 conditionals, 64 total clicks
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