Essential Charting Elements PEM - Emergency medicineBe sure to use the Powernote, instead of the...

OVERVIEWOFESSENTIALCHARTINGELEMENTSFORUNMPEDIATRICED*

ALL CHARTING NEEDS TO BE FINISHED AT THE END OF YOUR SHIFT PRIOR TO LEAVING THE EDIF YOU HAVE ANY QUESTIONS, ASK FOR HELP!

Allofthefollowingsectionsmustbeaddressedforanotetobeconsidered complete

Minimum:1. Date&timeyouenteredtheroom2. EDAttending3. Yourname(EDResident,EDNP/PA,orother)4. Historylimitations(e.g.languagebarrier,age,etc.)

BEST chartsinclude:• “HistorySource”(whoelsewasintheroom– besureto

includetheinterpreter!)• “Arrivalmode”(e.g.ambulance,walking,etc.)

Goodcharting habit:IfanylanguageotherthanEnglishisdocumented onthechart,youshould askiftheywantaninterpreter. Iftheysayno,add“declined interpretation services” here.

Orifyouarefluent andusedanylanguageother thanEnglishaddthatinformation here.

BASIC INFORMATION

HISTORY OF PRESENT ILLNESS

Minimum:1. Pleasefreetext theHPI.(ClickUseFreeText ortype

underNotes.)2. Pleasealsoselect4ormoreindividualHPIelements.

• Whileredundant,codersfrequentlymisselementsinafreetextHPI,butclickingelementsalonemakestheHPIunreadable.Pleasedoboth!

• Whenthehistoryisunobtainable,thereasonwhyandanyattemptstoobtainitfromasourceotherthanthepatientshouldbedocumented.

REVIEW OF SYSTEMS

Minimum:1. Clickonpertinentelementsforareview ofsystemsor

freetextin“other”fieldsasappropriate.2. Click“Allsystemsotherwisenegative”.

BEST charts:• Level4chartingneeds2-9systems• Level5chartingneeds10ormore(asking“anythingelse”

counts!)• YoumayalsousethemacrobyclickingontheblueMby

ReviewofSystems.

HEALTH STATUS

Minimum:1. Allergies(NKDAworks)2. Medication list(youcanalsouse“LaunchMedsList”but

askthefamilyformedicationchangesincomplexpatients)

3. Immunizations

BEST charts:• Bewarethatthisparagraphisusuallycollapsedbecause

Cernerauto-importsthisdata.Clickon“ShowStructure”(where“HideStructure”isabove)toexpandthisareatocleanuptheimporteddata.

Goodcharting habit:“Unable toobtain” isonly appropriate duringaresuscitation.Ifthechildcannottalk, gettheROSfromtheparents.

Crafted by:SaraSkarbek MDNatashaJamesMDDavidJolleyMD

Minimum:1. MedicalHistory(e.g. “nohospitalizations”)2. SurgicalHistory(e.g.“nosurgeries,”or“appendectomy”)3. FamilyHistory(e.g.“non-contributoryornoasthma”)4. SocialHistory (e.g.“livesinCuba,NM”)

BEST charts:• Bewarethatthisparagraphisusuallycollapsed.Besureto

clickon“ShowStructure”(where“HideStructure”isabove)toexpandthisareatocleanuptheimporteddata.

• YoumayalsousethemacrobyclickingontheblueMbyPast Medical/Family/SocialHistory.

PAST MEDICAL/FAMILY/SOCIAL HISTORY

PHYSICAL EXAM

Minimum:1. “Include VSfromflowsheet”andimportthetriagevital

signs.2. “IncludeO2satfromflowsheet”andimportthetriage

oxygensaturation.3. Atleast1elementforeachorgansystem.(Youmust

have8organsystems,whichareGen,Eyes,ENT,CV,Resp,GI,GU,MSK,Skin,Neuro,Psych,andLymph).

BEST charts:• NEVERusevitalsigns“Pernursesnotes.”• YoumayalsousethemacrobyclickingontheblueMby

PhysicalExamination.• Thisalsomeansyouneedtoperformatleast8physical

exammaneuvers!

MEDICAL DECISION MAKING

Minimum:1. Differentialdiagnosis:Clickonappropriateelements,addingthosenotlistedunder“other”2. Rationale:Freetextthereasonforyourplan.Whatareyouthinking?Whyareyoutestingornottesting?Whatdifferential

diagnosesareruledoutbasedonthehistoryandexamalone?Whyisthepatientsafefordischarge?3. Documents reviewed:IfyouspokewithEMS,lookedatnursingnotes,orhadrecordsfromanotherED,documentithere.You

mustincludethedateofthenotesyoureviewed,thesource,andasummaryofyourfindings.4. Orders:Use“LaunchOrderProfile”andincludetheordersenteredbyyouorotherEDproviders.Caution:Onlyincludeorders

bytheEDteamifthepatienthasbeenadmitted.Youmayhavetore-launchthisatdischargeoradmissiontoincludeallIVmedicationsgiven!Makesurethemedicationssaycompleted.

5. Resultsreview: Click “Lab results”toimportanylabsperformed.Seebelowonwheretointerpretthem.6. Insertradiologystudies.Clickon“Other”intheRadiologyresultssentenceandtype“=edradlast2days”inthepop-upbox.You

willhavetocleanitupabitbutthisisaloteasierthancopying/pasting.Seebelowonwheretointerpretthem.7. EKG:IncludeEKGfindingsifobtained.YoumayalsousethemacrobyclickingontheblueM.

Goodcharting habit:Thissmallsection isthe“meat”ofthenote! Puttimeandthoughtintoit!

Goodcharting habit:Lookatandinterpret allradiologic studiesobtained.

Include BOTHyour interpretation ANDtheradiology read!

Afterimporting labs,interpret them.Youshouldinterpret abnormal labsunder“Abnormal results”.

Radiology readhere(underOther) Yourreadhere(underEPinterp)ORusingthemacronexttothestudy(e.g.CXR)

Youonlyneedtoputtheinterpretation foronestudyiftherearemultiplestudiesresulted.

Minimum:1. Fordiagnosis,click“Other.”Free-textyoursuspected

diagnosis.Ifyoudon’tknowwhattoput,asktheattending!

2. Anyconsultsyouspokewith.Includethetimeandthegeneraldiscussionyouhadwiththem.

BEST charts:• Thenameofthespecialistyouspokewithandtheir

position(e.g.residentorfellow).

IMPRESSION

DISCHARGE PLAN

Minimum:1. Includethetimeofdischarge/admission.Includea

disposition(e.g.“home”ifdischarginghome,“Inpt”ifadmittedtopediatrics,“Surgery”ifadmittedtosurgery,or“Obs”ifadmittedtotheobservationunit).

2. Use“PrescriptionWriter”foranyprescriptions,orfreetextthescriptyouwrote.“Rxprovided”isnotsufficient.

3. Use“Pt.education”(seetipsonnextpage).4. Include“Follow-up”(e.g.“seePCP in2-3days”).Ata

minimum includef/uwithPCPin1weekasneeded.

BEST chartsinclude:• Add“Condition”• Includea“Reasonfordelay”underDispositionif

indicated.• Include“Dispositionedby”andputyournamehereAND

include“Supervisionprovidedby”andputyourattending’snamehere.

• Ifyousignthepatientout,use“Ptcaretransitionedto”insteadandputtheresident’snamewhoistakingover.

REEXAMINATION

Anytimeyougobackintoapatientroomorwaitedforaconditionchange,youcaninsertthetimeyourecheckedthepatientandyourassessment.Thisisgreatfor“Patienttoleratedliquidsbymouth”forkidswhocomeinwithvomitingorfordocumenting newvitalsigns.Thisalsoisagreatspottoaddyourexamaftertakingovercareaftersign-out.

ADDITIONALHELPFULCERNERCHARTINGTIPS!

REEXAMINATION: Repeat

Ifyoureexaminethepatientmorethanonce,youcanrepeatthisfield.Justrightclickon“Reexam/Reeval (rpt)”andthe abovedrop-downbox appears.Clickon“Repeat”andasecondboxwillappearbelowthefirst.

Ifsomeone elseputinare-examinationbeforeyoucouldchartyoursorifyouneedtoreorderthereexaminationsyoucanusethesamedrop-downboxtomoveyourReexaminationupordownusing“Moveup”or“Movedown”toreorderthem.

REEXAMINATION: Move-up or Move-down

WordstoAvoid Alternatives

LETHARGIC(unless youareplanning onanLP)

Somnolent,decreasedactivity, sleepy,drowsy

IRRITABLE Fussy,crying

OBSERVE Monitor(suggestsaction)

BesuretousethePowernote, insteadoftheUrgentCaretemplatetocapturealloftheelementsneededforcharting!

Right clickon“Procedures”anduse“Insertsentence…”tolocatetemplatesforcommonprocedures (e.g.lacerationrepair,proceduralsedation,etc.).Ifthereisnotemplatefree-textitintheprovidedbox.• Besuretoincludethenameofthepersonperformingthe

procedure!• Remember thatproceduresdonebynursingandtechscount

such ascerumenremovalandsplintapplications.• Besuretoincludeareexaminationnoteafterallprocedures.

PROCEDURES

RULES

Rightclickon“MedicalDecisionMaking”andclickon“Insert sentence…”toaddadecisionrule.Wereallyonlyhaveoneforclosedheadinjury,butlookformoreinthefuture!

Thenextboxwillappear.Clickthedoubledownarroworscrolltothebottomtofind“Rules.”Clickon“Rules”andthenon“PECARN.”Thiswillinserttherowbelowwhereyoucaneasilyinsertprewrittenexplanations.

PATIENT EDUCATION

IntheDISCHARGE PLANsectionfillouthomecareinstructions(under“patienteducation”)foralldischargedpatients.Thequalityisvariablebutyourattendingsorfellowscanshowyouwheretofindgoodones.Usethesearchboxtofindappropriatehomecareinstructions(besuretheALLbuttonisselected).Theabovesearchisfor“fever.”Doubleclickonthedesiredform.

Thiswill droptheinstructionsintothefieldontheleft.Youcanmodifyanythingintheinstructions.Anexampleis:“DavewasseenforX.HehasY.Pleasedo[insertinstructionsfortreatment].Pleaseseehisregulardoctorin[insertatime].Ifhehas[conditionstoreturn]orifyouhaveanyotherconcernspleaseseeadoctororreturntotheemergencydepartment.”

IFTHEPATIENTWASSEDATED:THISSECTIONMUSTINCLUDEPROCEDURAL SEDATIONDISCHARGEINSTRUCTIONS

Goodcharting habit:Youcaninclude amapandphonenumbertooutpatient clinics byenteringtheclinicname(or“custom”)inthesearchbox.

Tomakethisstepeasyit isbesttocompletetheImpressionandDischargePlaninthenotebeforethisstep.Whenthepatientisreadytogohome,clickon“Depart”forthefollowingscreen.

PATIENT DISCHARGE

Clickonthepenciliconsnexttothefouritemslistedontheleft:“MedRec/Prescriptions,”“PatientEducation,”“AppointmentReferral,”and“ReadyforDischarge.”IfyouhavefinishedtheImpressionandDischargePlaninthenote,thePatientEducationboxwillalreadybedone!

ThepenciliconnexttoMedRec/Prescriptionsistocompleteamedicationreconciliation(dothisforalldischarges)ThepenciliconnexttoPatientEducationistocompletehomecareinstructions(seepriortip)ThepenciliconnexttoAppointmentReferralisrecommendedforreferrals(seenexttip)

Besuretoincludeanupdatedpatientphonenumberonthereferralpage!ThepenciliconnexttoReadyforDischargeputsthedischargeorderin.

Clickthebox“Patientgiveneducationmaterialfromthechart”ontheleft,Print,andthenSign.Attachtheprintedhomecareinstructionstothephysicalchart.Askwheretoputthecharttocommunicatewithnursingthatthepatientisreadytogo!

PATIENT REFERRAL

TheAdHoc buttoncanalsobeusedforpatientreferralbutisnotpreferredastherearefeweroptions.

Clicking onthepenciliconforAppointmentReferralwillbringupthePowerOrdersMenu.ClickonEDAppointmentsandReferralstobringupthiscareset.

Scroll tothebottomtofindthePediatricSpecialtyCare(notshownbelow).Selecttheappropriateclinicandfillouttheconsultform.Thissignalstotheclinicthattheyneedtocallthefamilyforanappointment.Tomakesurethepatientisnotlost tofollow-updoBOTHof thefollowing:1. Besuretoincludeanupdatedpatient/familyphonenumberontheclinicreferralpage!2. Besuretogivethefamilytheclinicinformation(seePatientEducation– earliertip)