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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)