Chart NOS

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  • \ \ CC: year old with pertinent PMH/PSH presents with
  • \ HPI:
    • Characteristics obtain from interview with patient:
      • Quality of symptom:
      • Onset:
        • acute,
        • subacute,
        • chronic,
      •   Circumstances at time of onset:
        • pt unable to recall
      •   Since onset:
        • constant,
        • intermittent,
        • resolved, asymptomatic at this time,
        • improving,
        • worsening,
      • Description of quality of symptom:
        • painful,
          • sharp,
          • dull,
          • pressure,
          • burning
      • Location:
      • Provocation:
        • none
      • Alleviation:
        • none,
      • Associated symptoms
        • none
      • History of similar symptom is past
        • never
      • Outcome of symptom in past
      • History unfortunately limited
        • secondary
          • to patient’s condition,
          • to requirement of emergent diagnostics/interventions that take precedence over extensive history,
          • to patient’s lack of understanding of their medical conditions,
          • to patient’s lack of cooperative with interview,
          • to lack of medical records for this patient available in our system,
          • to lack of patient bringing medical information
    • \
    • \ Pertinent positives:
    • \ Pertinent negatives:
  • \\ REVIEW OF SYSTEMS:
    • Much of this set of ROS can be generally obtained by asking: Are you sick now or recently sick? Any pain anywhere in your body other than what we spoke about? Any vomiting or changes in your bowel habits? Any bleeding from anywhere?
    • \ Constitutional:
      • fevers,
      • rigors,
    • \ ENT:
      • rhinorrhea,  otalgia, sore throat
      • as noted in HPI
    • \ Eye:
      • vision grossly intact
      • as noted in HPI
    • \ Cardiac:
      • chest pain,
      • LE swelling,
      • no unilateral LE swelling
      • as noted in HPI
    • \ Pulmonary:
      • shortness of breath,
      • cough,
      • as noted in HPI
    • \ GI:
      • abdominal pain,
      • nausea,
      • vomiting,
      •   BRBPR, dark tarry stool,
      • diarrhea
      • as noted in HPI
    • \ GU:
      • no dysuria,
      • no discharge,
        •  male specific:
          • no testicular pain,
        • female specific:
          • no abnormal vaginal bleeding,
      • as noted in HPI
    • \ Nuero:
      • no recent severe headache outside of normal headaches per patient,
      • no recent ALOC,
      • moves all 4 extremities without any clear focal deficits,
      • Focused Neurological Exam:
        • CN II-XII intact,
        • vision grossly intact,
        • PEERL,
        • EOM intact,
        • strength symmetric intact at major flexion and extension joints throughout UEs and LEs,
        • no sensory deficits (per patient with light touch),
        • cerebellar function intact (finger-nose-finger),
        • normal gait in ED,
        • no sensory deficit in GU region,
        • able to squeeze buttock,
        • normal rectal tone,
      • as noted in HPI
    • \ MSK:
      • no recent trauma
      • no focal weakness,
      • no pain in extremities or joints,
      • as noted in HPI
    • \ Pysch:
      • normal speech,
      • normal affect,
      • linear though process,
      • no SI,
      • no HI,
      • appears able to care for self by evidence of being dressed, groomed, linear though processes expressed for history and plan after discharge,
      • no AH,
      • no VH,
      • as noted in HPI
    • \ ID:
      • no recent antibiotics,
    • \ Endo:
      • no polyuria/polydipsia
      • as noted in HPI
  • \\ PMH/PSH/PSFH:
    • \ PMH/PSH:
      • medical/surgical history pertinent to chief complaint as noted in HPI
    • \ SH:
      • domiciled,
      • \ tob,
      • \ etoh use,
        • .
        • Pt advised not to drink/drive/use concurrent sedating meds/drugs/etoh.
      • illicit drug use,
        • specifically
        • Pt advised not to drink/drive/use concurrent meds/drugs/etoh and offered cessation resources.
    • \ FH:
      • review and non-contributory to patient’s presenting complaint.
  • \\ EXAM:
    • \ VITALS: (overall impression of vital signs with repeat vitals in EMR as RNs re-access patient):
      • General
        • Vital signs in/near range of normal, not suggestive of acute emergent pathology.
        • Elevated BP: Advised patient to follow up for recheck/eval with PMD for elevated BP, asymptomatic.
      • Interpretted
        • HR:
            • good chronotropic response
            • asymptomatic,
        • BP:
          • normotensive.
          • hypertensive
            • (attempted to inform pt to advise to f/u with PMD).
          • hypotensive.
        • O2 sat:
          • hypoxia on my interpretation of pulse oximetry,
          • peri baseline O2 sat,
        • RR:
          • respiratory rate,
    • \\ PHYSICAL EXAM:
      • \ Constitutional:
        • well-nourished,
        • distress,
      • \ HEENT:
        • vision grossly intact,
        • hearing grossly intact.,
        • vision
          • 20/20 bilaterally,
        • EOM intact,
        • PERRLA pupils equal, round, reactive to light and accommodation 
        • intraocular pressures wnl,   normal pressures under 20
        • confrontation visual fields intact,   check for no visual field defect
        • external examination non-remarkable,
        • slit lamp exam:
          • lids/lashes lacrimal system without lesions,
          • conjunctiva/sclera: white and quiet, no injections,
          • cornea: clear,
          • anterior chamber: no cell or flare,
          • iris: round pupil,
          • lens: clear, no cataracts,
          • anterior vitreous: no inflammation/hemorrhage,
        • fundoscopic exam:
          • no papillary edema,
          • no splinter hemorrhage,
        • fluorescein exam:
          • no areas of uptake,
      • \ Cardiovascular:
        • RRR,
        • tachycardic,
        • no r/m/g,
        • no LE swelling,
        • no LE asymmetry,
        • no JVP,
      • \ Pulmonary:
        • Lungs CBTA,
        • No respiratory distress, non-labored breathing
        • Speaking comfortably in full sentences,
        • symmetric breath sounds
        • wheezing,
          • (inspiratory and expiratory),
          • (expiratory only),
        •  significant decreased aeration
        • rales,
          • throughout,
          • at bases bilaterally,
        • rhonchi,
        • respiratory distress,
          • mild,
          • moderate,
          • severe,
      • \ GI:
        • abdomen soft,
        • abdomen non-tender in all 4 quadrants,
        • TTP diffusely
        • TTP in RUQ,
        • TTP in RLQ,
        • TTP in LLQ,
        • TTP in LUQ,
        • TTP in epigastric region,
      • \ Neuro:
        • Normal LOC.
        • No gross focal neurological deficits.
        • Somnolent though protecting airway.
        • CN II-XII intact,
        • no facial asymmetry
        • PERRL,
        • strength intact throughout,
        • sensation grossly intact throughout,
        • normal reflexes,
        • ambulatory,
        • with steady gate,
        • no dysmetria,
        • no dysarthria,
      • \ MSK:
        • no deformities,
        • moving all extremities,
        • id="dds-272-exam_ambulation" name="exam_ambulation" class="bracket-drop-down" style="margin: 0; padding: 0 10px;"> type="text" value=" " selected="selected"> type="text" value="non">non ambulatory,
        • Focused exam at affected area
          • nuero intact
          • muscular intact
          • vascular intact
          • no deformities,
          • id="dds-278-exam_bonettp" name="exam_bonettp" class="bracket-drop-down" style="margin: 0; padding: 0 10px;"> type="text" value=" " selected="selected"> type="text" value="no">no bony tenderness to palpitation
          • id="dds-279-exam_range" name="exam_range" class="bracket-drop-down" style="margin: 0; padding: 0 10px;"> type="text" value=" " selected="selected"> type="text" value="no">no full range of motion,
      • \ Pysch:
        • Normal speech.
        • Demonstrates linear thinking.
        • SI,
        • HI.
        • Exam / appearance / presentation consistent with gravely disabled.
        • No AH/VH.
        • Agitated.
        • Confused.
      • \ GU exam:
        • \ Male specific exam:
          • Exam chaperoned
            • by
          • Testicular exam:
            • no testicular tenderness,
            • normal testicular lie,
            • able to elicit cremaster reflex,
          • Penile exam:
            • no discharge at meatus
            • non-erect
          • Prostate exam:
            • enlarged prostate
            • bogginess and tenderness
        • \ Female specific exam:
          • Exam chaperoned,
            • by ,
          • no CMT,
          • no adnexal TTP,
          • no abnomral discharge
          • no active vaginal bleeding,
          • vaginal bleeding from os,
          • atraumatic, no cervical lacerations
        • \ Rectal exam:
          • Exame chaperoned
            • by
          • guiac
          • brown stool in vault,
          • no visible external hermorroids,
          • no palpable internal hemorroids,
          • thought appreciate limited sensitivity of DRE
    • Focused Exam:
  • \\ ED COURSE and MDM:
  • \ Working Impression/Empiric Management:
    • \
      • \
  • \ Diagnostically:
    • \ Point of Care Testing:
      • \ Pregnancy Test
        • negative
      • \ POC gluc
        • wnl
      • \ POC Hg
        • wnl
      • \ iStat
        • potassium wnl
        • hyperkalemia
        • no base deficit
      • \ lactate
        • wnl
    • \\ EKG (as interpreted by prelim ED):
      • Non-remarkable EKG. No evidence of ischemia. NSR, regular rate, normal intervals, no abnormal TWI, no ST elevation/depression.
      • Rate
        • normal,
        • bradycardic,
        • tachycardic,
      • \ ST-segment morphology:
        • TWaves:
          • No abnormal TWI,
          • Abnormal TWI,
          • Non-specific repolarization abnormalities,
          • No ST depression, ST depression,
          • No ST elevation, ST elevation but does not meet STEMI criteria, meets STEMI criteria and cath lab activated,
      • \ Comparison to prior:
        • Unchanged when compared to prior,
        • Attempted but no old EKG available for comparison,
        • ,
      • \ Summary to pt’s clinical condition:
        • Normal EKG – not suggestive any pathology elucidated on EKG, Non-specific repolarization abnormalities – no definitive evidence of active ischemia on EKG, Evidence on EKG concerning for active ischemia.
      • \ Rhythm:
        • Regularly regular:
          • NSR,
          • Sinus tachycardia,
          • Sinus bradycardia,
        • Irregularly irregular:
          • Atrial fibrillation with normal ventricular rate,
          • Atrial fibrillation with RVR,
        • Regularly irregular:
          • tachycardic,
            • Atrial flutter with RVR,
          • bradycardic,
            • Heart block,
              • Type: ,
      • \ Intervals:
        • Narrow QRS,
          • supraventricular:
            • irregular:
              • AVRT (considering pre-excitation, considering WPW, etc),
                • Tx: Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.
                • Tx: Synchronized cardioversion.
                  • Per ACLS 120-200J.
            •  regular:
              • AVNRT (considering supraventricular tachycardia),
                • Tx: Adenosine 6mg IV push,
                  • Refractory, therefore second dose 12mg IV push
                • Synchronized cardioverson.
                  • 100 J
                  • per ACLS for narrow regular 50-100J
        • Wide QRS,
          •  bradycardic:
            •  low junctional escape/ventricular origin,
          • tachycardic:
            •  regular:
              •  stable,
                •  Amiodarone 150mg IV / 10 min
                  •  Refractory, repeated PRN recurrence of VT.
                  •  Maintenance 1mg/min x 6 hrs.
                •  Procainamide (20-50mg/min until arrhythmia suppressed, hypotension, QRS duration >50%, or max 17mg/kg. Maintenance 1-mg/min.
                • synchronized cardioversion
                  •  100 J (per ACLS)
              •  unstable:
                •  with pulse. Therefore Unstable Ventricular Tachycardia with Pulse.
                  •  Synchronized cardioversion (per ACLS 100J).
              •  pulseless. Therefore pulseless ventricular tachycardia. ACLS initiated: (CPR. Defibrillation 200 J Biphasic. Epi 1mg. Continuation of ACLS.)
    • \\ Labs:
      • Ordered, pending at this time, including:
        • CBC,
        • BMP,
        • LFTs/lipase,
        • UA,
        • Urine Cx
        • lactate
        • Blood Cx
          • x2
        • CK,
        • EtOH level,
        • Ingestion labs (acetaminophen, ASA),
        • Troponin,
        • Delta troponin,
        • BNP,
        • HIV,
        • Influenza,
        • Urine toxicological screen,
        • CRP,
        • ESR,
      • \ Reviewed and interpreted/correlated to clinical scenario to inform diagnosis and plan by me.
        • No significant labratory abnormalities contributory to patient’s presentation.
        • Non-emergent abnormalities which I informed the patient about and advised for prompt outpatient follow up for outpatient care.  
        • Specifically:
        • CBC:
          • No significant unexpected anemia, No significant leukocytosis, No thrombocytopenia.
          • Hg
            • anemia,
              • transfusion indicated given
                • symptomatic
                • < 7 Hg (6-8 range from restrictive transfusion strategy)
                • active significant bleeding
              • transfusion not indicated (considered)
              • peri-baseline,
              • significantly lower than baseline
              • unknown baseline,
              • suspected iron deficiency contributory, will advise/rx Ferrous sulfate 325mg daily w/ vit C.
          • wbc’s
            • luekocytosis
              • suspect demarginalization given lack of infectious findings on hx/exam,
              • suggestive of infectious process,
              • concerning for malignancy, advised to for follow up
            • leukopenic
              • neutropenic
                • ((ANC < 500))
          • platelets:
            • thrombocytopenic
              • ((platelets < 150k))
              • transfusion not indicated
                • given suspected consumptive process
                • ((ITP, TTP, HIT))
            • transfusion indicated given
              • <10 k (regardless that pt is asymptomatic)
              • <20k and and planned CVP or pt febrile
              • <50k and planned LP or neurosurgical procedure
          • pancytopeniac
            • likely 2/2 chemo
            • likely 2/2 HIV
            • likely 2/2 hep C
            • unclear etiology, will initiate eval w/ completion of eval and monitoring/treatment to be continef as outpatientafter ED
        • \ BMP:
          • No significant pathologic electrolyte derangements.
          • AKI,
            • 50% increase from baseline
            • BUN/Cr >20 suggestive of prerenal process,
              • will administer IVF
              • and recheck
          • CKD,
            • grossly unchanged from prior,
          • Hyperkalemia,
          • Anion gap
            • ((> 12))
          • acidotic suggested by low bicarb,
        • \ LFTs/lipase:
          • No laboratory evidence of hepato-biliary pathology.
          • Transaminitis without elevated bilirubin, suggestive of hepatic pathology
          • Elevated direct bilirubin suggestive of biliary pathology
          • Elevated indirect bilirubin suggestive of increased rbc breakdown
        • \ UA:
          • Not consistent with urinary tract infection.
          • Urine Cx sent with follow mechanism in place
          • Equivocal for infection
            • Empirically treated.
            • UCx sent with f/u mechanism in place
        • \ Cardiac Labs:
          • Troponin:
            • undetectable
            • <99th percentile
            • >99th percentile but under cut off for positive
            • positive
            •  
          • \ Delta troponin
            • pending, pt under care of other service at time of delta troponin,
            • undetectable,
            • <99th percentile,
            • >99th percentile but under cut off for positive,
            • positive,
            •  
          • \ BNP:
            • please note that greater than 500 suggests CHF, under suggests not CHF
            • not suggestive of CHF exacerbation
            • suggestive of CHF exacerbation
            • non-diagnostic
        • \ HIV:
          • negative,
          • positive,
            • I discussed this finding with patient in sensitive private manner, educated on treatment options, offered resources, answered all questions, advised to have partner evaluated and advised to refrain from any of the common modes of transmission.
          • Prior to test sent, pt was informed that we advise for testing for HIV. Pt did not opt out.
        • \ Influenza
          • negative
        • \ CK:
          • significantly elevated, requires trending,   usually for >500-1000k
          • mildly elevated, not anticipated to rise given negated precipitant,
          • not high enough to suggest concern for pathology,
        • \ Ingestion labs:
          • acetaminophen
            • non-detectable,
          • ASA:
            • non-detectable,
          • etoh
            • non-detectable,
            • positive
        • \ Urine toxicological screen:
          • negative
          • postive for
        • \ Markers of inflammation
          • CRP suggestive of more acute inflammation
            • wnl
            • elevated
          • ESR suggestive of more chronic inflammation
            • wnl
            • elevated
    • \\ Radiographically:
      • \ CXR:
        • Normal study: no tracheal deviation, non-widened mediastenum, normal cardiac boarder, no pleural effusion, no air under diaphragm, no focal consolidation, no PTX, no gross bony abnormalities.
        •  Pulmonary edema,
        •  Cardiomegaly,
        •  lobar opacity,
        • diffuse radio-opacities
        • pneumothorax
          • on right
          • on left
          • mediastenium midline
          • (This is an ED prelim radiographic interpretation in order to increase chance of finding obvious emergent pathology which can be intervened upon and to minimize delay in care secondary to delay of radiology to be able to provide formal reads. Given these studies require board certified radiologists to review and formal reads are beyond the scope of Emergency Medicine, institutional protocol in place which will alert current care team/patient for over-reads/changes/critical reads).
      • \ PXR (Pelvic XR):
        • no evidence of pelvic fracture
        • no evidence of hip fracture
        • appreciate limited sensitivity of PXR and therefore correlated clinically
      • \ XR of extremity
      • \ Advanced Imaging:
        • CT head:
          • negative for acute intra-cranial pathology
        • CT c-spine
          • negative for acute cervical neck pathology
        • CT chest
          • PE protocol
            • negative for PE
          • angio
            • negative for aortic dissection
        • CT a/p
          • w/ contrast,
          • non-con,
          • negative for acute intra-cranial pathology
        • CT of extremity:
          • with venous contrast:
          • with arterial contrast:
          • non-con:
    • \ Consultations:
      • Discussed case with of the service who kindly recommended
      • Discussed case with who kindly agrees to come evaluation patient and provide recommendations.
      • Obtained the collateral information to assist in ED care for patient
        • advises
      • Time of consultation:
  • \ Therapeutically:
    • \ Empirically:
      • \ Anti-platelet agent: ASA
        • Empirically administered given ddx includes ACS and potential benefit outweighs potential harm
        • 162mg PO chewed
        • 325mg PO chewed
      • \ IVF
        • 30 cc/kg,
        • 250cc,
        • 500cc,
        • 1 L,
        • 2 L,
      • \ Analgesia:
        • acetaminophen,
        • ibuprofen,
        • hydrocodone/acetaminophen (pt informed not to drive/drink/take fall precautions/not make significant decisions for remainder of day)
        • morphine,
        • ketorolac,
        • hydromorphone
        • haloperidol (haldol)
          • indication:
            • sx refractory to other analgesia,
            • side effect profile of opioids likely to exacerbate symptoms,
          • 3mg
            • IV
            • IM
          • 5 mg
            • IM
            • IV
          • 10mg
            • IM
      • \ Anti-emetics
        • ondansetron (zofran),
          • IV,
          • ODT oral dissolving tablet
        • metoclopramide (reglan),
          • 5 mg,
          • 10mg,
          • PO,
          • IV,
          • IM,
        • lorazepam,
          • indication:
            • prolonged QTC make risk of other similar medications that would prolong QTC prudent to avoid,
            • sx refractory to other anti-emetics,
        • haloperidol (haldol)
          • indication:
            • sx refractory to other anti-emetics,
            • pain refractory to other analgesia,
            • suspected to have quality of component of pain that may benefit from analgesic effects,
          • 3mg
            • IV
            • IM
          • 5 mg
            • IM
            • IV
          • 10mg
            • IM
      • \ Anxiolytic
        • lorazepam
          • 0.5 mg
          • 1 mg
          • 2mg
          • PO
          • IV
          • IM
    • \ Anti-biotics:
      • Timing:
        • administered as promptly as source identified with sufficient likelihood to inform appropriate antibiotics (goal directed)
        • administered when source identified
        • administered within 1 hrs from triage
        • administered within 3 hrs from triage
      • Regimen:
        • ceftriaxone 1 g IV
        • ceftriaxone 1g IV / azithromycin 500mg IV
        • vancomycin IV / cefepime 1 g IV /  azithromycin 500mg IV
        • ceftriaxone 1g IV / metronidazole 500mg IV
        • Unasyn
        • vancomycin / zosyn
        • cefazoline (ancef) 1 g IV
  • \\ Assessment/Plan:
    • year old with PMH/PSH of
    • presented with
    • evaluation is most consistent with
      • \
    • \ Concurrent evaluation for secondary problem is consistent with
    • DDx includes but in not limited to (pt does not meet reasonable likelihood/consistency with the dx to warrant additional pursuit of these entities (risks outweigh benefits of non-indicating testing)
      • \
        • \
          • \
            • \
    • \ Plan:
      • \
        • \
  • \\ Re-evaluation:
    • Unchanged on re-evaluation.
    • Improved on re-evaluation.
      • On thorough re-evaluation, after patient was observed on telemetric monitoring, patient remains hemodynamically stable, normal vital signs, with clear sensorium, repeat cardio-pulmonary-abdominal exam benign, is ambulatory, has no new development of pain, pain is well-controlled and is amenable to discharge after observation period in the ED.
      • Neurologically Intact.
        • Patient has normal speech, clear sensorium, exhibits linear thinking, able to articulate plan for aftercare, and exhibits normal fine motor skills.
        • Abdominal Benign. Repeat abdominal exam  did not reveal any tenderness in any of the four quadrants. No rebound their guarding. patient  tolerated PO fluids and food to the emergency department without any recurrence of abdominal pain or vomiting.
      • Respiratory status
        • No signs of respiratory distress on exam, able to speak in full sentences without dyspnea. Respiratory related vital signs reassuring and suggestive of improvement. Improved respiratory exam compared to prior.
        • Unchanged respiratory status compared to prior.
        • Worsening respiratory status compared to prior.
      • Clinically Sober.
        • Patient demonstrates clinical sobriety.
          • speak non-slurred speech
          • is alert and oriented
          • ambulatory with steady gate
          • has fine motor intact
          • able to articulate plan for safe aftercare upon discharge from ED.
        • Re-evaluation after sobriety did not reveal any new symptoms/signs. Unlikely initially unappreciated pathology on initial eval given patient has no new complaints and re-examination does not reveal any new abnormalities suggestive of previously undetected pathology.
        • Instructed patient to exercise cautions after discharge
        • Patient requests discharge, will oblige demonstration of capacity, sobriety, and no unevaluated pathology.
    • On re-evaluation, remains intoxicated. Hemodynamically stable. Will continue observation.
    • \
  • \\ Diposition:
    • home.
      • Counseled patient on assessment, impression, plan.
        • Discussed disposition options with patient after counseling as above and included option for continued observation in medical setting however shared decision making yielded joint decision for disposition to home with self and family observation, prompt follow up with PCP, and return to ED precautions.  Counseled patient on complaint specific return precautions given that there are pathologies that, while sufficiently unlikely to warrant further investigation at this time, may develop/worsen after discharge.  Counseled that early in a disease progress, a work up can be falsely non-revealing of more significant pathology however this does not exclude the possibility of developing serious pathology thereby underscoring the importance of prompt follow-up with PMD and low threshold for return to ED as needed.
    • Observation
      • Indication:
    • Admitted,
      • transfer of care kindly assumed by admitting team
      • at
      • level of care,
      • with service.
    • Sign out at change of shift, transition of care kindly assumed by oncoming ED team
      • to
      • pending
      • at
    • Eloped.
      • Patient eloped prior to my full evaluation of patient. Patient noted by nursing staff to be walking, in no apparent distress and no suggestion of intoxication or altered mental status or psychiatric impairment that would suggest that patient does not have capacity. Therefore while I was unable to complete evaluation, it appears that patient has capacity based upon collateral to make decision to leave and ability to return should the patient desire medical evaluation. Therefore policy of calling patient overhead multiple times to encourage patient to return for eval started however patient did not return
    • AMA.
      • Documentation of AMA.
      • The patient insisted to leave AMA (against medical advice).    The patient exhibits:
      •   \ Capacity.
        • The patient was clinically not intoxicated, free from distracting pain, appears to have intact insight, judgment and reason and in my medical opinion has demonstrated capacity to make this medical decision to leave AMA. In this scenario, it would be battery to subject a patient to treatment against his/her will. I have voiced my concerns for the patient’s condition given that a full evaluation and treatment had not occurred.
      • \ Articulates understanding of symptoms and signs and my concerns as the provider.
        • The patient and I have discussed the need for further evaluation to determine if their symptoms and signs are caused by a condition that would cause permanent disability, long term pain/suffering, development of morbidity which could in addition could require advanced medical care, hospitalization, and procedures that could be very costly and possibly averted by full evaluation and treatment at this time.  I explained that these could cause problems which would prevent them from being able to work or care for themselves independently, and even lead to death.  The patient demonstrated understanding of these risks to me.
      • \ Exhibits understanding of limitations of evaluation.
        • I explained that the limited evaluation performed was not conclusive nor sufficiently able to exclude pathological processes and that by being partially evaluated, this could lead to a false reassurance of well-being when in fact serious pathology had not yet been elucidated.
      • \ Exhibits understanding of advised treatment plan
        • which includes remaining in the ED for additional evaluation, diagnostics, and treatment.
      • \ Exhibits understanding of foregoing additional evaluation/treatment.
        • The risks of leaving that I explained and the patient verbalized back (I included a broad set of complications given that the work up was incomplete and definitive diagnosis was not know) including: immediate deterioration of health, long term disability (both neurological and physical), infection with sepsis, loss of limb or ability, loss of ability work, organ failure leading to death, and death without preceding symptoms to allow patient to get back to an Emergency Department quickly enough to treat
      • \Was offered alternatives to advised plan.
        • Treatments to mitigate risk for patient (given with uncertainty from incomplete work up):
          • Empiric treatment based upon presumptive suspicion of etiology though this was balanced with risk of causing harm from treating the incorrect etiology of the patient’s s/s given diagnostic uncertainty at that point in the work up.
          • I attempted to offer alternative treatments even with the patient leaving (while being very clear that the treatment would be suboptimal care and thereby place the patient at risk for the same morbidity/mortality as described (I used non-medical words to describe these concepts).  This was my hope that the patient may be amenable to partial or empiric treatment contingent upon it being safe and less likely to cause harm that help patient even if they insisted against our strongest medical advice to stay.
          • Additionally, I tried offering alternative options or options for patient comfort (sandwich, water,warm blanket, turning off alarms in pt’s room, offer for SW to come and assist with any psychosocial issues or financial concerns, and also offered analgesia or other symptomatic relief), in hopes that the patient might be amenable to partial evaluation and treatment which would be medically beneficial to the patient.
        • \ AMA form:
          • pt signed, placed in chart.
          • pt refused to sign secondary, had ability to sign but was unfortunately unwilling
        • \ Questions. I addressed all questions, implored importance of follow up, and re-iterated return precautions.
          • Unfortunately despite all attempts, the patient declined and insisted on leaving. Because I have been unable to convince the patient to stay, I answered all of their questions about their condition and asked them to return to the ED as soon as possible to complete their evaluation/treatment regardless of how they feel but especially if their symptoms worsen or do not improve. I emphasized that leaving against medical advice does not preclude returning here for further evaluation and we would welcome their return to continue their evaluation at any time. I strongly encouraged the patient to return to this or any Emergency Department at any time if they are not willing to do so, at least to contact their PMD in hopes that the patient may at least have as much care to reduce risk to the extent that they are willing to do so.
        • \ Witness to this interaction and patient’s departure against my medical advice:
        • \ It is my dear hope that the patient will return to my care, the care of one of my colleagues, or to the care of another physician to order to ensure the safety of the patient.
    • \\ DIAGNOSIS:
    • \ COUNSELING:
      • Patient/family educated to the extent possible in terminology matched to their understanding on diagnostics, assessment, and treatment plan along with the risks inherent to the diagnostics and therapeutics and plan. Patient/family amendable and in agreement with above plan. All questions and concerns addressed and answered.
      • Attempted shared decision making in discussion with patient/family in all circumstances where feasible and possible.
      • \ Attempted to explain and obtain patient’s approval for plan however unable to do so secondary to patient’s condition and the requirement of emergent evaluation and interventions.
    • \ SUPERVISION:
      • With attending MD. Discussed and obtained approval/confirmation of evaluation (history, exam, diagnostics) and plan (assessment, interventions, disposition) with ED attending physician
      • With resident physician. I have evaluated the patient and discussed the patient’s history, exam, diagnostics, and plan with the resident physician and agree with plan as stated by resident physician.
  • \\  Additional documentation:
      • ((Of note, to bill for critical care time, the primary diagnosis must be one of the diagnoses below))
      • ICD-10 code:  
    • \ OBSERVATION NOTE:
      • Total observation time
      • Start of observation time
      • End of observation time
      • Decision for disposition made after observation. Disposition to
      • Observation performed in order to attempt to safely preclude an inpatient admission.
      •  \ Observation was performed given
        • diagnostic uncertainty (i.e. serial examinations and assessments by me to elucidate likelihood of a pathologic process).  
        • to determine intensity therapy required (i.e. there was a reasonable possibility that by observing the patient’s response to therapy, an admission may be abated and safely discharged). 
      • \ Observation by me in ED.
      • \ The observation was utilized as the primary diagnostic tool during that time.
      • \ Of note, additional history was obtained at this time and there was no family history contributory to the patient’s current condition. 
      • \ Given patient had initial complaint concerning for significant deterioration resulting in severe morbidity and potential mortality, patient required direct observation and monitoring in the emergency department with trending of vital signs, telemetric monitoring reviewed by me, frequent reassessments by nursing with communication with me of status, re-accessments in addition by me, which were all required for patient’s safety during that time (monitoring while administering medications with risk for CNS/cardiac/pulmonary adverse reactions) and to determine patient’s disposition by assessing for response to interventions/treatment. Patient was observed under my supervision.
      • \ Revenue code: 0762.  HCPCS Code G0378
    • \ CRITICAL CARE PROCEDURE NOTE:
      • Authorized and performed by: Attending physician
      • \ Total critical time:
        • minutes.
          • CPT Code  
      • \ Indication for critical care including pt has exhibited risk factors for and symptoms and signs concerning for impending deterioration included compromise of
        • airway,
        • respiratory stability,
        • cardiovascular collapse,
        • CNS irreversible damage,
        • metabolic derangements
        • renal failure
        • fulminant hepatic failure
      • \ PRIMARY DIAGNOSIS:
        • ((primary diagnosis must be one of these for critical care time to be documented))
      • \ Due to patient having a presentation that is concerning for a potentially pathologic process causing an resulting in significant morbidity and potential mortality, the patient required emergent evaluation in the emergency department including emergent diagnostics, emergent assessment and evaluation, and emergent and directed treatment in order to mitigate risk for life-threatening deterioration. The critical care time as indicated above included discussing history with patient, examining patient, interpreting vital signs including pulse oximetry, initiating and interpreting diagnostics, and clinical acumen in order to synthesize patient’s presentation to develop treatment plan and emergently implement the requisite steps. This part of my care the patient is exclusive of other billable procedures, specifically procedures, treating other patients, and any educational time. Please refer to the above rationale for further documentation regarding the critical nature of the patient during my care.
      • \ This critical care time is separate from teaching or other separately billable procedures or treating other patients.
    • Of note, follow up over-read mechanism in place for over-reads and follow up of pending diagnostics.

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