Epic Dot phrases VCU
CLARRS
ClinkalternativesrisksbenefitsrationalSetting
Clear and consistent choice
link medication condition to current decision
Understand risks and benefits of available options
Rationalize information process in reasonable way
Not made in the setting of acute worsening of underlying depression, psychosis, etc.
Capacity
Capacity Requirements:
___Patient demonstrates the ability to delineate a clear and consistent choice
___Patient demonstrates an understanding of their medical conditions and their link to current decision (i.e. knowing medication list if responsible for own home medications)
___Patient able to identify available alternative treatment options (i.e. going home vs staying in hospital, declining surgery for favor of medication interventions only, etc.),
___Patient able to weigh risks and benefits of available options in order to come to a conclusion that is consistent with their goals
___Patient able to process information provided in a rational/reasonable way
___ Patient's choice not made in the setting of an acute worsening of underlying depression, psychosis, etc.
Patient appears to lack capacity to make a consistent discharge decision at this time. Lacking even one element of capacity requirements may be grounds for patient losing capacity.
- Per Virginia state code, the primary service is required to have documentation of their own assessment of the patient's capacity.
___Patient demonstrates the ability to delineate a clear and consistent choice
___Patient demonstrates an understanding of their medical conditions and their link to current decision (i.e. knowing medication list if responsible for own home medications)
___Patient able to identify available alternative treatment options (i.e. going home vs staying in hospital, declining surgery for favor of medication interventions only, etc.),
___Patient able to weigh risks and benefits of available options in order to come to a conclusion that is consistent with their goals
___Patient able to process information provided in a rational/reasonable way
___ Patient's choice not made in the setting of an acute worsening of underlying depression, psychosis, etc.
Patient appears to lack capacity to make a consistent discharge decision at this time. Lacking even one element of capacity requirements may be grounds for patient losing capacity.
- Per Virginia state code, the primary service is required to have documentation of their own assessment of the patient's capacity.
- recommend- recommend re-evaluation of patient, as patient's mental status is currently waxing and waning.
- per the consult question of capacity for patient to leave AMA, at the time of evaluation the psychiatry team determined
This patient does not have capacity regarding refusal to leave AMA prior to appropriate medical stabiliztion, as the patient fulfills 2/4 criteria of the criteria below to demonstrate capacity:
o The patient can communicate a clear and consistent choice, yes, would like to go home.
o The patient can demonstrate understanding of the relevant information, unclear at this time. Patient states he know what medications he needs to take when he goes home but is unable to repeat back to provider what they are. He is also unsure of when he would need to take these medications.
o The patient can demonstrate an appreciation of the situation and its consequences as it applies to the patient, patient demonstrated a cursory understanding and stated he is "ok" with dying and believes it is his right to do so. He denied SI.
o The patient can rationally manipulate information, unclear at this time.
This capacity assessment is specific to the decision regarding leaving the hospital prior to medical stabilization at this point in time. This assessment of capacity cannot be extrapolated to unrelated decisions without further assessment.
Please note: The primary team must also document their capacity assessment as 2 providers are required to remove a patient’s capacity. The primary team’s assessment is the main assessment, and Psychiatry is a second opinion.
Additional information regarding capacity:
Capacity can be fluid and can be reversible. Only one provider is needed to restore capacity
The primary team will need to identify a surrogate decision maker to make medical decisions for the patient while they are determined to not have capacity
Capacity is not synonymous with competency. Capacity is fluid and is determined by health care providers. Competency is a permanent determination made by a court of law. re-evaluation of patient, as patient's mental status is currently waxing and waning.
- per the consult question of capacity for patient to leave AMA, at the time of evaluation the psychiatry team determined
This patient does not have capacity regarding refusal to leave AMA prior to appropriate medical stabiliztion, as the patient fulfills 2/4 criteria of the criteria below to demonstrate capacity:
o The patient can communicate a clear and consistent choice, yes, would like to go home.
o The patient can demonstrate understanding of the relevant information, unclear at this time. Patient states he know what medications he needs to take when he goes home but is unable to repeat back to provider what they are. He is also unsure of when he would need to take these medications.
o The patient can demonstrate an appreciation of the situation and its consequences as it applies to the patient, patient demonstrated a cursory understanding and stated he is "ok" with dying and believes it is his right to do so. He denied SI.
o The patient can rationally manipulate information, unclear at this time.
This capacity assessment is specific to the decision regarding leaving the hospital prior to medical stabilization at this point in time. This assessment of capacity cannot be extrapolated to unrelated decisions without further assessment.
Please note: The primary team must also document their capacity assessment as 2 providers are required to remove a patient’s capacity. The primary team’s assessment is the main assessment, and Psychiatry is a second opinion.
Additional information regarding capacity:
Capacity can be fluid and can be reversible. Only one provider is needed to restore capacity
The primary team will need to identify a surrogate decision maker to make medical decisions for the patient while they are determined to not have capacity
Capacity is not synonymous with competency. Capacity is fluid and is determined by health care providers. Competency is a permanent determination made by a court of law.
- per the consult question of capacity for patient to leave AMA, at the time of evaluation the psychiatry team determined
This patient does not have capacity regarding refusal to leave AMA prior to appropriate medical stabiliztion, as the patient fulfills 2/4 criteria of the criteria below to demonstrate capacity:
o The patient can communicate a clear and consistent choice, yes, would like to go home.
o The patient can demonstrate understanding of the relevant information, unclear at this time. Patient states he know what medications he needs to take when he goes home but is unable to repeat back to provider what they are. He is also unsure of when he would need to take these medications.
o The patient can demonstrate an appreciation of the situation and its consequences as it applies to the patient, patient demonstrated a cursory understanding and stated he is "ok" with dying and believes it is his right to do so. He denied SI.
o The patient can rationally manipulate information, unclear at this time.
This capacity assessment is specific to the decision regarding leaving the hospital prior to medical stabilization at this point in time. This assessment of capacity cannot be extrapolated to unrelated decisions without further assessment.
Please note: The primary team must also document their capacity assessment as 2 providers are required to remove a patient’s capacity. The primary team’s assessment is the main assessment, and Psychiatry is a second opinion.
Additional information regarding capacity:
Capacity can be fluid and can be reversible. Only one provider is needed to restore capacity
The primary team will need to identify a surrogate decision maker to make medical decisions for the patient while they are determined to not have capacity
Capacity is not synonymous with competency. Capacity is fluid and is determined by health care providers. Competency is a permanent determination made by a court of law. re-evaluation of patient, as patient's mental status is currently waxing and waning.
- per the consult question of capacity for patient to leave AMA, at the time of evaluation the psychiatry team determined
This patient does not have capacity regarding refusal to leave AMA prior to appropriate medical stabiliztion, as the patient fulfills 2/4 criteria of the criteria below to demonstrate capacity:
o The patient can communicate a clear and consistent choice, yes, would like to go home.
o The patient can demonstrate understanding of the relevant information, unclear at this time. Patient states he know what medications he needs to take when he goes home but is unable to repeat back to provider what they are. He is also unsure of when he would need to take these medications.
o The patient can demonstrate an appreciation of the situation and its consequences as it applies to the patient, patient demonstrated a cursory understanding and stated he is "ok" with dying and believes it is his right to do so. He denied SI.
o The patient can rationally manipulate information, unclear at this time.
This capacity assessment is specific to the decision regarding leaving the hospital prior to medical stabilization at this point in time. This assessment of capacity cannot be extrapolated to unrelated decisions without further assessment.
Please note: The primary team must also document their capacity assessment as 2 providers are required to remove a patient’s capacity. The primary team’s assessment is the main assessment, and Psychiatry is a second opinion.
Additional information regarding capacity:
Capacity can be fluid and can be reversible. Only one provider is needed to restore capacity
The primary team will need to identify a surrogate decision maker to make medical decisions for the patient while they are determined to not have capacity
Capacity is not synonymous with competency. Capacity is fluid and is determined by health care providers. Competency is a permanent determination made by a court of law.
FASTHUGS
Feeding/fluids:
Analgesia:
Sedation:
Thromboprophylaxis PPx:
Head up position:
Ulcer prophylaxis:
Glycemic control:
Spontaneous breathing trial:
Analgesia:
Sedation:
Thromboprophylaxis PPx:
Head up position:
Ulcer prophylaxis:
Glycemic control:
Spontaneous breathing trial:
Delirium: Hospital delirium
Delirium Risk Factors and Exacerbating Factors: Change in usual environment/routine, sleep disruption, acute illnessPatient specific: NA
Active Orders reviewed for potentially inappropriate medications: NA
Delirium Precautions:
• Avoid overnight/early AM lab draws, change to 6AM
• Treat pain and avoid overtreatment of pain
• Maintain sleep wake cycle (minimize nighttime interruptions, manage blinds and windows, increase interaction and stimulation during daytime)
• OOB to chair as much as able (please use least restrictive activity orders and re-evaluate daily)
• Provide eyeglasses and hearing aids
• Avoid benzos, anticholinergics, muscle relaxants
• Reschedule medications to avoid nighttime administration and to promote periods of rest
• Reorient and provide companionship.
• Minimize restraints, lines, tubes
• Minimize use of antipsychotics. Use only for patient and staff safety issues only.
• CAM/CAM-ICU screen qshift. If positive, utilize Delirium Prevention and Management orderset.
NSTEMI
Presented with 10/10 chest pain started today w/ associated ***. First started ***. Pain improved w/ nitroglycerin. Biomarkers continued to rise, peak ***. EKG showing ***
- s/p ASA loading dose, cont ASA 81 daily
- started heparin drip
- s/p plavix load, cont 75 daily
- lipid panel and A1c ordered for risk stratification and optimization
- TTE ordered, can start Beta blocker after EF assessment
- start atorvastatin 80 daily
- may benefit from MRA and SGLT2
- continue to trend trop and CKMB until peak
- tele, daily EKG
- replete electorlytes PRN: K >4, Mag >2
- NPO at MN for LHC tomorrow
Presented with 10/10 chest pain started today w/ associated ***. First started ***. Pain improved w/ nitroglycerin. Biomarkers continued to rise, peak ***. EKG showing ***
- s/p ASA loading dose, cont ASA 81 daily
- started heparin drip
- s/p plavix load, cont 75 daily
- lipid panel and A1c ordered for risk stratification and optimization
- TTE ordered, can start Beta blocker after EF assessment
- start atorvastatin 80 daily
- may benefit from MRA and SGLT2
- continue to trend trop and CKMB until peak
- tele, daily EKG
- replete electorlytes PRN: K >4, Mag >2
- NPO at MN for LHC tomorrow
Procedure Note
@TD@
@NOW@
Indication:
[ ] lack of adequate peripheral iv access
[x] infusion of medications with high risk of extravasation injury
[x] hemodynamic monitoring
[ ] renal replacement therapy
[ ] other
Time Out :
[ ] was completed immediately prior to the start of the procedure which included verification of the correct patient, correct site and agreement on the procedure to be done.
[ ] was not done because procedure was emergent
Type of Central Line Being Placed:
[ ] Central venous – Triple Lumen
[ ] Hemodialysis – Trialysis
[ ] Cordis
Length: {Blank single:19197:: "Cordis","15cm","20cm", "24cm"}
Location:
[ ] Internal Jugular Vein [ ]right [ ]left
[ ] Subclavian Vein [ ]right [ ]left
[ ] Femoral Vein [ ]right [ ]left
Consent:
[ ] indications/risks/benefits explained to patient/family and consent obtained
[ ] no consent obtained because procedure emergent
Central Line Bundle:
[x] I washed/disinfected my hands prior to starting procedure
[x] Hat [x] Mask [x] Sterile gown
[x] Sterile gloves were worn throughout the procedure
[x] Everyone in the room during the procedure wore a mask
[x] Sterile technique was used throughout the procedure
Anesthetic Used:
[x] 1% Lidocaine without epinephrine [ ] Other
Procedure:
[x] Patient placed in Trendelenburg position. Site examined with ultrasound and patent/compressible vein identified. Chlorhexidine used to prep the skin. Sterile field and full body drape used to cover the patient.
[x] Ultrasound probe inserted into sterile sheath and local anesthetic infiltrated. Access needle was advanced into the lumen under direct ultrasound guidance. Blood was freely aspirated.
[x] Guidewire advanced and placement confirmed via ultrasound guidance.
[x] Skin incision made, dilated over the guidewire, and the catheter was inserted.
[x] After insertion, blood was aspirated through each port and flushed clear. The catheter was secured with sutures, cleaned, and a sterile occlusive dressing was applied.
Ultrasound Guidance:
[x] Yes [ ] No
Description/Findings:
[x] Dark non-pulsatile blood return obtained from all ports
[x] Placement confirmed by ultrasound
[ ] Other
Complications:
[ ] None apparent
[ ] Other
Follow-up x-ray: pending
Procedure Performed By: {Blank single:19197:: "Dr. ***", "@MEMD@"}
Collaborating Physician (For APPs): {Blank single:19197:: "N/A", "Dr. ***"}
Assistant(s): ***
Discussed with Dr. ***
Electronically signed by @MEMD@ on @TD@ at @NOW@
Arterial Monitoring Line Placement
Procedure Note@TD@
@NOW@
Indication:
[x]hemodynamic monitoring
[ ]other
Time Out :
[x]was completed immediately prior to the start of the procedure which included verification of the correct patient, correct site and agreement on the procedure to be done.
[ ]was not done because procedure was emergent
Location:
[ ]Radial [ ]Right [ ]Left
[ ]Femoral [ ]Right [ ]Left
Consent:
[ ] indications/risks/benefits explained to patient/family and consent obtained
[ ] no consent obtained because procedure emergent
Sterile Prep:
[x]I washed/disinfected my hands prior to starting procedure
[x]Hat [x]Mask [x]Sterile gown
[x]Sterile gloves were worn throughout the procedure
[x]Everyone in the room during the procedure wore a mask
[x]Chlorhexidine was used to prep the skin
[x]Full body drape was used to cover the patient
Anesthetic Used:
[x]Lidocaine [ ]Other
Ultrasound Guidance:
[x]yes [ ]No
Sterile Technique Used Throughout Procedure?
[x]Yes [ ]No
Allen's Test Performed Prior to Procedure?
[ ]Yes - Findings normal, good capillary refill in all fingers [ ]No
Procedure: Using modified seldinger technique, the appropriate vessel was located with the catheter placed. Wire advanced once "flash" returned. Pulsatile flow was verified and a good arterial waveform verified by bedside monitor. The site was reprepped with chlorprep solution followed by a suture to secure the line and placement of a sterile dressing. Hemostasis was assured at the termination of procedure.
Complications:
[ ]None apparent
[ ]Other
Procedure Performed By: {Blank single:19197:: "Dr. ***", "@MEMD@"}
Collaborating Physician (For APPs): {Blank single:19197:: "N/A", "Dr. ***"}
Assistant(s): ***
Discussed with Dr. ***
Electronically signed by @MEMD@ on @TD@ at @NOW@
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