Interpreting the Electronic Medical Record Pitfalls, Advantages and Risks. Alan L. Nager MD, MHA Children s Hospital Los Angeles
|
|
- Ezra Hodges
- 5 years ago
- Views:
Transcription
1 Interpreting the Electronic Medical Record Pitfalls, Advantages and Risks Alan L. Nager MD, MHA Children s Hospital Los Angeles
2 No Financial Disclosures $ $ $ $ $ $ $ $
3 NOT a Lecture on: Pitfalls of billing A lecture on HIPAA issues Comparison of paper vs EMR One EMR system vs another
4 Lecture is on: The meaning behind the ED Electronic Medical Record
5 Clinician Process
6 Decision-Making Process Medical education has always been focused on content, rather than medical decision making BUT now Clinical reasoning Medical problem solving Diagnostic reasoning Critical analysis Bias reduction
7 Watch out for Cognitive Errors Faulty hypothesis generation failure to consider the question and/or if the data fits Faulty context formulation hypothesis is too narrowly focused; may be related to lack of knowledge and experience Faulty information gathering and processing - Is the problem common or uncommon - Anchoring: reliance on insufficient information and making decisions too early - Vertical line failure: failure to consider other diagnoses with same symptoms
8 Cognitive Errors (cont d ) Premature closure: failure to consider reasonable alternatives after the initial diagnosis is made Faulty verification: failing to use a final check to ensure causal relationship - If the diagnosis doesn't fit, don t use it! - Can be altered by physician fatigue, inability to access data, end-of-shift rush, cost considerations, reliance on others, inadequate or lack of communication, etc.
9 A thorough and detailed process MUST be in sync with ALL the components documented on the EMR (not partial, sort of, almost, close to )
10
11 EMR Documentation Garbage in Garbage out
12 Published Issues EMR s provide improved safety and quality and better outcomes for patients EMR s are vulnerable to crashes and need for repairs Systems are not designed for individual complex patients - systems are made for the masses No one reporting system to track problems, shortcomings and pitfalls with the EMR
13 Published Issues (cont d) Institute of Medicine (IOM) has recommended that all software manufacturers be required to report deaths, serious inquiry or unsafe conditions related to information technology EMR technology is being pushed without patient notification or consent, raising ethical considerations EMR s makes it too easy to come to conclusions without demonstrating the thinking process
14 Benefits Readable Can be learned More efficient More accessible Less expensive
15 Benefits (cont d) Accurate billing Track trends QI tracking Searchable
16 Benefits (cont d) Research options Editable note Triggers warnings Multiple users
17 Detractions Timeconsuming Poorly designed Lack of organization General templates Downtimes
18 Detractions (cont d) Stimulus overload Human slowdown Long fix-it time Visible to others
19 Detractions (cont d) Cyberhacking Timestamped entries Technical glitches Note bloat
20 Personal Factors Influencing Risk Time constraints Template efficiency Acuity of patients Electronic agility Baseline knowledge Linguistic clarity Consult notes Notes on wrong patient
21 Personal Factors (cont d) Missing records e.g. arrest RN-MD inconsistencies Incomplete orders (fluids, etc.) Pharmacy mistakes Handoff errors All systems negative Ignoring alerts Non-chronological notes Process not translated to EMR
22 Personal Factors (cont d) Reliance on trainee notes No or incomplete progress notes NOT PROOFING EMR
23 System Factors Influencing Risk System does not eradicate human error (omissions, deviations or failures) System limitations, such as: no max drug doses, no fluid limits Difficult to determine clinician entries if multiple Issues related to sudden downtime Difficulty if supervising/documenting trainees work Drop-down menu not always accurate
24 System Factors (cont d) Reliance on templates, but risk with free texting Risk on pediatric patients using adult templates Not all systems incorporate labs, vital signs or nurses notes System does not highlight abnormal results System may be logical but not medically friendly Some documents may not be electronic (DNR, AMA, consents, arrest records)
25 System Factors (cont d) Person, not system must integrate all documents System doesn t demand timely notes Can use copy/paste which carries risk System doesn t know who is typing on an open computer EMR s DON T PROOF ONLY HUMANS DO
26 Risk Management Risk management refers to strategies that reduce and minimize the possibility of an adverse outcome, harm or loss Risk management techniques improve patient care, consider safety and reduce the chance of an adverse outcome or malpractice claim
27 Let s Play What s the legal risk???
28 Simple Risk Errors Adrenoleukodystrophy - S P BMT Diagnosis: Altered mental state Chronic Back Pain Diagnosis: Lower back pain Lumbosacral disc herniation Osteoporosis Discharge Instructions: Ice Inguinal Hernia Gastrointestinal: Soft, mild tenderness to palpation in periumbilical area and RLQ. No guarding. Genitourinary: Normal
29 Simple Risk Errors (cont d) Lethargy - Intubated General: Alert, in respiratory distress Cardiac - 3 Surgeries Cardiovascular: Regular rate and rhythm. No murmur or gallop. Normal peripheral perfusion and pulses Anaphylaxis ROS: Allergy/immunologic symptoms: no seasonal allergies
30 Simple Risk Errors (cont d) Liver Transplant - Sepsis Rationale: Given history and exam, will d/w with liver transplant prior to obtaining labs Incomplete History History of Present Illness The patient presents with abdominal pain. Additional pertinent history: 24 hours of abdominal pain in RLQ, vomiting, anorexia, fever
31 Simple Risk Errors (cont d) Chronic Dx Diagnosis: Viral URI with cough *Sickle cell disease/fever Sepsis - Lethargic General: Alert, appropriate for age Cooperative, smiling, well appearing
32 Simple Risk Errors (cont d) Vital Signs x 1 (6 mo old) Temperature Route Temperature Heart Rate Respiratory Rate Systolic Blood Pressure Diastolic Blood Pressure Mean Arterial Pressure Oral 36.9 deg C 83 bpm 18 breaths/min 111 mm HG 64 mm HG 80 mm HG
33 Case 1 5 y/o autistic male with abd pain 1 day F 1 day. Pain is periumbilical, left lower quad, no D, dec po with adequate UOP 38.5, 149, 22, 108/72, exam normal Rationale: patient presents with V, needs UA to R/O UTI Dx: Vomiting, viral syndrome Patient returned and had surgery
34 Case 2 4 y/o with complex history, presents with cough, wheezing and difficulty breathing. Patient has hypoxic ischemic encephalopathy with resultant spastic quadriplegia, trach, etc. Exam multiple finding; 28 diagnoses Summarized medication list includes 36 medications including clonidine 100 µg per/ml suspension 0.4 mg GT, TID Pt admitted for pneumonia and respiratory distress
35 Case 3 15 y/o presents with pancytopenia, rash 2 days, sore throat. Previously seen in hematology clinic and evaluated for lab abnormalities. Working diagnosis there was nutritional etiologies. Plan for possible bone marrow aspiration in the future Exam 39.3, 110, 18, 104/71 with mild abnormalities WBC 2.5, Hgb 10, platelets 30, other lab findings Consulted Heme. Will have follow-up clinic visit
36 Case 4 9 y/o presents with abdominal pain and constipation x 4 days. PMD gave Colace but didn t use it. No F, N, V, D, dysuria, but urinating more,? weight loss. Good appetite, no weight loss Exam 36.8, 90, 24, 99/69 RLQ tenderness UTI, appendicitis workup Dx: Constipation (treated in ED) Home with miralax and follow-up
37 Case 5 15 y/o with high-grade osteosarcoma, left humerus, discharged yesterday after chemotherapy of cisplatin, doxorubicin. Patient has V x20 and abdominal pain, no F, not able to keep down fluids, UOP 1 Exam 36.6, 86, 18, 101/70, very dehydrated Obtained labs, 60ml/kg IVF, discussed with oncology Sent home but returned with complications
38 Case 6 3 mo, 52 day NICU stay, twin gestation; cough wheezing and respiratory distress. Shortly after arrival unresponsive with cyanosis. Exam 39.2, 122, 16, 54/22 unresponsive but perked up with oxygen. Rhonchi and wheezing on lung exam. Difficult IV access, plan to intubate and transfer Intubation challenges
39 Case 7 11 mo presents with F 4 days, D 3 yesterday, no V, one of his testicles look swollen when crying, UOP normal. Exam 37.4, 124, 30, 96/52 mild dehydration Oral fluid tolerated, negative UA, sent home Dx: Viral syndrome, diarrhea Oncology information obtained 2 days later
40 Case 8 3 yo with ADD, severe tantrums on tegretol, clonidine and risperidone presents with 1.5 weeks headache, F, URI, drinking well, acting normal Exam 38.3, 110, 20, 110/66 alert active running around Decision to do labs, LP and admit for observation 2 days later, falling, unsteady gait, HA s Transferred for definitive diagnostic workup
41 Risk Reduction Strategies Educate users on EMR risks Develop quality improvement (QI) program directed toward EMR case evaluation Publicize analysis of cases regarding deviations, omissions and discuss learning points Teach critical analysis regarding cases Provide data trends to end-users
42 Risk Strategies (cont d) Provide intermittent feedback and updates. Easy to fall back into old documentation habits Conduct general risk management training sessions for all EMR users and test risk knowledge
43
Pediatric Case Studies. Case 1
Pediatric Case Studies James Naprawa, MD Assistant Clinical Professor Pediatric Emergency Medicine Children s Hospital, Columbus Case 1 Almost 4 year old AA girl PMH UTI x 2 with abdominal pain and fever
More informationH&P Checklist (Inpatient) Evaluator: Subject: Program:
H&P Checklist (Inpatient) Evaluator: Subject: Program: PROFESSIONALISM 1) Introduces self/role and preceptor Did 2) Verbal and non-verbal language demonstrates respect for patient & family. Did 3) Respects
More informationOBSERVATION UNIT ASTHMA PATHWAY OUTLINE Westmoreland Hospital PAGE 1 OF 5
PAGE 1 OF 5 Exclusion Criteria: (Reason to admit to hospital) A. New EKG changes except sinus tachycardia B. Respiratory Rate > 40 C. Signs/symptoms of Heart Failure D. Impending respiratory failure or
More informationBoot Camp Transfusion Reactions
Boot Camp Transfusion Reactions Dr. Kristine Roland Regional Medical Lead for Transfusion Medicine, VCH Objectives By the end of this session, you should be able to: Describe in common language the potential
More informationEmergency Department Triage
Emergency Department Triage Julia Fuzak, MD, Patrick Mahar, MD The Children s Hosital Denver, CO, USA 1/30/09 Hospital Pediatrico Juan Manuel Marquez Habana, Cuba Objectives What is does triage mean? Why
More information* Final Report * ED Triage Entered On: 01/16/2014 8:45 EST Performed On: 01/16/2014 8:42 EST by
Result date: Result status: 16 January 2014 8:42 EST Auth (Verified) * Final Report * ED Triage Entered On: 01/16/2014 8:45 EST Performed On: 01/16/2014 8:42 EST by Assessment I Chief Complaint : Diarrhea
More informationReal Cases: Bad Outcomes
Real Cases: Bad Outcomes Fredrick M. Abrahamian, D.O., FACEP, FIDSA Clinical Professor of Medicine UCLA School of Medicine Director of Education Department of Emergency Medicine Olive View-UCLA Medical
More informationWhy is an outpatient transplant best for you?
Outpatient Autologous Transplant Why is an outpatient transplant best for you? An outpatient transplant allows you to: stay in the comfort of your own home sleep in your own bed eat your usual foods be
More informationCASE-BASED SMALL GROUP DISCUSSION
MHD I, Session 11, Student Copy Page 1 CASE-BASED SMALL GROUP DISCUSSION MHD I SESSION 11 Renal Block Acid- Base Disorders November 7, 2016 MHD I, Session 11, Student Copy Page 2 Case #1 Cc: I have had
More informationDIVISION OF CARDIOLOGY
Name: Date of Birth: / / Home Phone #: Cell Phone #: Work Phone #: Fax #: Address: City: State: Zip: Primary Care Physician: Office Address: Work #: Fax #: Referring Physician (if different): Office Address:
More informationSCRIPT 1 - PHYSICIAN COMMUNICATION Localizing Signs and Symptoms with Warning Signs
SCRIPT 1 - PHYSICIAN COMMUNICATION Localizing Signs and Symptoms with Warning Signs Wisconsin Healthcare Associated Infections in LTC Coalition PHONE CONTACT NECESSARY Resident: Jimmy Issick Date: 11/7/15
More informationEMS Report Writing. Principles and Elements of Quality PCR Reports. David Ghilarducci MD FACEP
EMS Report Writing Principles and Elements of Quality PCR Reports David Ghilarducci MD FACEP Outline For This Session Role of the EMS PCR The Narrative Section w SOAPP Format Why We Write Reports Patient
More informationScottsdale Family Health
Please list pharmacy you would like us to use for your medications. Pharmacy Phone Number Fax Number Since your last visit: 1. Have you been diagnosed with any new medical conditions? Yes No If Yes (give
More informationTraztuzumab (Herceptin)
Traztuzumab (Herceptin) Information for patients Chemotherapy Name Hospital No Your consultant is Important Advice Always carry your chemotherapy alert card. It is important that you know what to do if
More informationHow We Think and.pitfalls! Manish Suneja, MD Scott Vogelgesang, MD
How We Think and.pitfalls! Manish Suneja, MD Scott Vogelgesang, MD Five Quick Questions Take a piece of paper and write down your answers to each of these 5 questions You have about 5 seconds for each
More informationNEW PATIENT VISIT QUESTIONNAIRE
HeartHealth A Program of the Dalio Institute of Cardiovascular Imaging NEW PATIENT VISIT QUESTIONNAIRE Name: Date of Birth: / / Address: City: State: Zip: Home Phone #: Work Phone #: Cell #: Email: Preferred
More informationPractical Approaches to Medical Necessity
Practical Approaches to Medical Necessity CAROLYN AVERY, CPC, CEMC CAROLYN AVERY & ASSOCIATES, PC ROBERT OSSOFF DMD, MD, CHC ASSISTANT VICE CHANCELLOR FOR COMPLIANCE &CORPORATE INTEGRITY VANDERBILT MEDICAL
More informationBlood/Blood Component Utilization and Administration Annual Compliance Education
Blood/Blood Component Utilization and Administration Annual Compliance Education This course contains annual compliance education necessary to meet compliance and regulatory requirements. Instructions:
More informationStudent Guide Module 5: Management of Prevalent Infections in Children Following a Disaster
Student Guide Module 5: Management of Prevalent Infections in Children Following a Disaster Objectives for this session Section I - Integrated Management of Childhood Illness (IMCI) Understand the IMCI
More informationNortheast Ohio Urogynecology Patient History Intake Form. Last Name First Name Age. Date of Birth Race Referring Physician.
Northeast Ohio Urogynecology Patient History Intake Form Last Name _First Name Age_ Date of Birth Race Referring Physician Reason for Visit: _ Allergies: Preferred Lab (circle): QUEST LABCARE PLUS LABCORP
More informationOutcome. Communication
Outcome Child returned to ED 14 mos later C/o vomiting and headaches Head CT - large tumor, ependymoma (small tumor noted on 1 st CT) He died few years later Lawsuit- $5 million settlement Communication
More informationMCKAY UROLOGY LINCOLNTON OFFICE PATIENT HISTORY FORM
Patient name: MRN #: Current Medications (prescription and over the counter medications including vitamins, herbs, aspirin, antacids, injectables, hormones and birth control medication) If you brought
More informationTransarterial Chemoembolization (TACE)
Transarterial Chemoembolization (TACE) Princess Margaret Know what to expect Read this booklet to learn: What TACE is...1 How TACE works...2 The benefits of TACE...3 The risks and side effects of TACE...3
More informationFever Phobia and the ED Doc Ran Goldman, MD (rgoldman@cw.bc.ca) BC Children s Hospital, Professor, University of British Columbia SLIDES ON : www.clinicalpeds.com/whistler Define Fever 38.0 o Doesn t
More informationThe Crashing Pediatric Patient: Stopping the Fall
The Crashing Pediatric Patient: Stopping the Fall I can t breathe... 4 year old BIBA from school with sudden severe resp distress Hx of asthma, food allergies Judith Klein, MD FACEP Assistant Professor
More informationEVALUATION OF A SICK CHILD WITH FEVER
EVALUATION OF A SICK CHILD WITH FEVER Learning objectives At the conclusion of this learning activity, participants should be able to; Discuss the different etiologies of acute illness in a child Identify
More informationI understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference.
1. Patient Rights and Responsibilities Acknowledgement I understand that as a patient, I have both rights and responsibilities. I have received a copy of this document for my reference. 2. Notice of Privacy
More informationCOALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 510
COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION - Medications POLICY NUMBER: 510 Effective Date: August 31, 2006 SUBJECT: CARE OF THE INDIVIDUAL RECEIVING CLOZAPINE 1. GENERAL: Clozapine
More informationTEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM
TEXAS VASCULAR ASSOCIATES, P.A. PATIENT CLINICAL INTAKE FORM PATIENT NAME: DATE OF BIRTH: TVA Physician being seen: Date of Visit: PAST MEDICAL HISTORY HEART PROBLEMS NEUROLOGICAL Congestive Heart Failure
More informationUnderstand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the
Understand the scope of sepsis morbidity and mortality Identify risk factors that predispose a patient to development of sepsis Define and know the differences between sepsis, severe sepsis and septic
More informationHeadache Follow-up Visit Form
!1 Headache Follow-up Visit Form We will be unable to see you unless this form is completely filled out. We appreciate your thoroughness. Name DOB Age Today s Date Referring doctor: Primary doctor: Neurologist:
More informationHeart Failure with Johnny Crash: LEFT VENTRICULAR EJECTION FRACTION (LVEF) SYMPTOMATOLOGY: Assess VENTRICULAR DYSFUNCTION HEART FAILURE:
Heart Failure with Johnny Crash: Joan E. King, PhD, ACNP-BC, ANP-BC Melissa Smith, DNP, ANP-BC Vanderbilt University School of Nursing HEART FAILURE: Heart Failure (HF): a complex clinical syndrome resulting
More informationObjectives. Case Presentation. Respiratory Emergencies
Respiratory Emergencies Objectives Describe how to assess airway and breathing, including interpreting information from the PAT and ABCDEs. Differentiate between respiratory distress, respiratory failure,
More informationPaediatric Enhanced Life Support Scenarios
Paediatric Enhanced Life Support Scenarios These scenarios should be used to assess staff undertaking the Paediatric Enhanced Life Support course within the Black Country Partnership NHS Foundation Trust.
More informationPLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS:
1 NAME: DATE OF BIRTH PLEASE LET US KNOW YOUR REASON FOR TODAY S VISIT : CURRENT MEDICATIONS (WITH DOSAGE) PLEASE INCLUDE VITAMINS AND HERBAL MEDICATIONS: PAST MEDICAL HISTORY (YOUR MEDICAL HISTORY) :
More informationPEDIATRIC RESPIRATORY ILLNESS MADE SIMPLE
Copyright 2012 Joel Berezow, MD and The Pediatrics for Emergency Physicians Network All rights reserved. Duplication in whole or in part, or electronic transmission in any form, is prohibited THE PEDIATRICS
More informationFIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA
Department of Radiation Oncology FIRST TIME VISIT APPOINTMENT CHECKLIST Department of Radiation Oncology 200 Medical Plaza, Ste B265 Los Angeles, CA 90095 310-825-9775 1. Complete ALL important Patient
More informationDocumentation Dissection
History of Present Illness: Documentation Dissection The patient is a 50-year-old male c/o symptoms for past 4 months 1, severe 2 bloating and stomach cramps, some nausea, vomiting, diarrhea. In last 3
More informationHASPI Medical Biology Lab 03
Patient 1001 is a 42-year-old female that is experiencing severe heartburn, abdominal pain, bloating, nausea, and vomiting. Ulcers Bleeding sores in the stomach or intestine Gallbladder Disease Gallstones
More informationCapital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History
Capital Health Medical Center - Hopewell NEUROSURGICAL-ONCOLOGY Patient History Please take a few minutes and complete the following questions before you see the doctors so that we may learn a bit more
More informationA Rapid Medical Screening Process Improved Emergency Department Patient Flow during Surge Associated with Novel H1N1 Influenza Virus
A Rapid Medical Screening Process Improved Emergency Department Patient Flow during Surge Associated with Novel H1N1 Influenza Virus Daniel B. Fagbuyi Kathleen Brown, David Mathison, Jennifer Kingsnorth,
More informationNURSING PROCESS FOCUS: Patients Receiving Amphotericin B (Fungizone, Abelcet)
NURSING PROCESS FOCUS: Patients Receiving Amphotericin B (Fungizone, Abelcet) ASSESSMENT Prior to administration: Obtain complete health history including allergies, drug history, and possible drug interactions.
More informationBaseline Vital Signs and SAMPLE History. Chapter 5
Baseline Vital Signs and SAMPLE History Chapter 5 Baseline Vital Signs and SAMPLE History Assessment is the most complex skill EMT-Bs learn. During assessment you will: Gather key information. Evaluate
More informationSEP-1 CHALLENGING CASES WITH DR. TOWNSEND
UW MEDICINE PATIENTS ARE FIRST SEP-1 CHALLENGING CASES WITH DR. TOWNSEND AMADAE AREVALO RN, MSN, CCRN KATIE MEHRING RN, BSN, CCDS AMANDA SIGALA, RN, BSN, MPH, CPHQ JUNE 12, 2018 OBJECTIVES 1. Summarize
More informationEffective Case Presentations
Effective Case Presentations Alan Lefor MD MPH Department of Surgery Jichi Medical University 4 4 Alan Lefor 1. History The complete medical history always should have six parts It begins with the Chief
More informationPentostatin (Nipent )
Pentostatin (Nipent ) Pentostatin (Nipent ) This leaflet is offered as a guide to you and your family. Your treatment will be fully explained by your doctor or nurse, who will be happy to answer any questions.
More informationReview of Neonatal Respiratory Problems
Review of Neonatal Respiratory Problems Respiratory Distress Occurs in about 7% of infants Clinical presentation includes: Apnea Cyanosis Grunting Inspiratory stridor Nasal flaring Poor feeding Tachypnea
More informationSleep History Questionnaire
Sleep History Questionnaire Name: DOB: Phone: Date of Consultation: Consultation is requested by: Primary care provider: _ Preferred pharmacy: Chief complaint: Please tell us why you are here: How long
More informationFever in the Newborn Period
Fever in the Newborn Period 1. Definitions 1 2. Overview 1 3. History and Physical Examination 2 4. Fever in Infants Less than 3 Months Old 2 a. Table 1: Rochester criteria for low risk infants 3 5. Fever
More informationSepsis Awareness and Education
Sepsis Awareness and Education Meets the updated New York State Department of Health (NYSDOH) requirements for Infection Control and Barrier Precautions coursework Element VII: Sepsis Awareness and Education
More informationPATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: EMERGENCY CONTACT INFORMATION PRIMARY INSURANCE INFORMATION
PATIENT INFORMATION Last Name: First Name: Middle: Date of Birth: Gender: SSN: Race: Marital Status: Address Line: City: State: Zip Code: Home Phone: Work Phone: Email Address: Cell Phone: Primary Care
More informationPLANNING/IMPLEMENTATION/EVALUATION Pt. Room: 2A (Include a RUBRIC for each)
PLANNING/IMPLEMENTATION/EVALUATION Pt. Room: 2A (Include a RUBRIC for each) Nursing Diagnosis Risk for decreased cardiac output r/t altered stroke volume secondary to sepsis. Long Term Goal Pt. will maintain
More informationFEVER. What is fever?
FEVER What is fever? Fever is defined as a rectal temperature 38 C (100.4 F), and a value >40 C (104 F) is called hyperpyrexia. Body temperature fluctuates in a defined normal range (36.6-37.9 C [97.9-100.2
More informationGASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT
GASTROENTEROLOGY PATIENT QUESTIONNAIRE - PLEASE PRINT Full name: Date: Telephone Number: Age: Address: Email address: CHIEF COMPLAINTS(List the problems about which you came to see the doctor) 1) 2) 3)
More informationRetinal Consultants of San Antonio PATIENT REGISTRATION
PATIENT REGISTRATION Today s Date Referred by Patient Full Name Home Address City State Zip Code Home Phone Cell Phone E-mail address Date of Birth Preferred Method of Contact: Home Phone / Cell Phone
More informationSTANDARDIZED PROCEDURE
Zuckerberg San Francisco General Hospital and Trauma Center Children s Health Center STANDARDIZED PROCEDURE REGISTERED NURSE 1 Zuckerberg San Francisco General Hospital Children s Health Center Standardized
More informationSEPSIS SYNDROME
INTRODUCTION Sepsis has been defined as a life threatening condition that arises when the body s response to an infection injures its own tissues and organs. Sepsis may lead to shock, multiple organ failure
More informationRisk Management in an Office Setting: Who are we sending home?
Risk Management in an Office Setting: Who are we sending home? October 1, 2016 Niagara Falls, NY The threat of litigation following a misdiagnosis or improper treatment presents a challenge to healthcare
More informationMedical Emergencies. Emergency Medical Response
Medical Emergencies Lesson 23: Medical Emergencies You Are the Emergency Medical Responder You are the emergency medical responder (EMR) responding to a scene on a downtown street involving a male who
More informationPatient Name Date of Birth MALE / FEMALE Date. Left handed or Right handed. Marital Status: Single Married Divorced Widowed Children?
PH NEW PATIENT HISTORY Patient Name Date of Birth MALE / FEMALE Date Occupation: Left handed or Right handed Marital Status: Single Married Divorced Widowed Children? Y or N # Previous Treating Physician:
More informationMHD I SESSION X. Renal Disease
MHD I, Session X, Student Copy Page 1 CASE-BASED SMALL GROUP DISCUSSION MHD I SESSION X Renal Disease Monday, November 11, 2013 MHD I, Session X, Student Copy Page 2 Case #1 Cc: I have had weeks of diarrhea
More informationPrescribe appropriate immunizations for. Prescribe childhood immunization as per. Prescribe influenza vaccinations in high-risk
Supplemental Digital Appendix 1 46 Health Care Problems and the Corresponding 59 Practice Indicators Expected of All Physicians Entering or in Practice Infectious and parasitic diseases Avoidable complications/death
More informationMary South, MD 3647 Medina Road Medina, OH Phone: Fax: has an appointment. on at AM/PM.
Mary South, MD 3647 Medina Road Medina, OH 44256 Phone: 234-205-2040 Fax: 234-205-2040 has an appointment on at AM/PM. To make sure your first visit goes smoothly, we ask that you complete the enclosed
More informationHomework Assignment Complete and Place in Binder
Homework Assignment Complete and Place in Binder Chapter # 34/35: Pediatric & Geriatric Emergencies 1. The first month of life after birth is referred to as the: A) neonatal period. B) toddler period.
More informationADVERSE EVENT REPORTING. Catherine Dillon, CCRP
ADVERSE EVENT REPORTING Catherine Dillon, CCRP Reporting Adverse Events Adverse Events (AEs) are... any untoward medical occurrence in a subject that was not previously identified which does not necessarily
More informationCase Presentation: Mr. S
Case Presentation: Mr. S History Seen as inpatient in May, but has significant prior history and is a poor historian 53 y.o. Male no PMH, has been out of contact with medicine for years aside from hernia
More informationInstruct patient and caregivers: Need for constant monitoring Potential complications of drug therapy
Assessment Prior to administration: Assess patient for chest pain, dysrhythmias, and vital signs (initially and throughout therapy) Obtain complete medical history, including allergies, especially heart
More informationJohn Sanchez, D.O. August 18, 2013
John Sanchez, D.O. August 18, 2013 Ø Coding Caps Ø Relevance to Clinical Practice Ø Current Guidelines 1995 (organ systems) 1997 (bullets) Ø Definitions ICD- 9 CPT E/M ( 99 _ ) Ø Who Should Determine the
More informationMANAGEMENT OF SICK CHILDREN GUIDELINES
MANAGEMENT OF SICK CHILDREN GUIDELINES Aim: To ensure that sick children are cared for swiftly and that appropriate action is taken to prevent the spread of infection. To use Staying Healthy Preventing
More informationMedical First Responder Program Protocols
Medical Scene Safety Protocol Verify Scene Safety with Police or Dispatch UNKWN Scene Safe? Enter Continue to Appropriate Protocol Possible to Make Safe Make Safe Then Continue Exit Area and Stage Outside
More information9/15/2017. Joyce Turner RN Director of Clinical Program Development
Joyce Turner RN Director of Clinical Program Development A toxic response to an infection that spirals out of control attacking the body s own organs and tissues. The infection can be bacterial, viral
More informationCECILIA P MARGRET MD PhD MPH Child, Adolescent and Adult Psychiatry NE 24th ST Suite 104, Bellevue WA 98007, Phone / Fax: +1 (425)
IDENTIFYING INFORMATION PATIENT INFORMATION FORM Patient's Name: DOB: Ethnicity/race: Gender: Primary language if other than English: Address: Phone: Home/ Mobile/ Work Email: Occupation: Marital Status:
More informationHASPI Medical Biology Lab 01a
! What Does It Test For? Very Low Low Glucose Electrolytes Ferritin Blood ph The glucose test measures the amount of sugar, or glucose, in the blood or urine. A very high or very low glucose test can indicate
More informationHistory Taking 3rd year Lecture. Thembi Katangwe 1st March 2011
History Taking 3rd year Lecture Thembi Katangwe 1st March 2011 Objectives To understand that the parent / guardian is the historian Build a rapport with parent/guardian as well as older children To understand
More informationSepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018
Sepsis Bundle Project (SEP) Kathy Wonderly RN, MSEd, CPHQ Consultant Developed: April 2015 Most recent Revision: December 2018 Objectives 1. To identify the symptom of severe sepsis and septic shock syndrome.
More informationChange in Condition: When to report to the MD/NP/PA
Change in Condition: When to report to the MD/NP/PA Immediate Notification Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked Change (i.e. more severe) in relation
More informationPast Medical History. Chief Complaint: Patient Name: Appointment Date: Page 1
Appointment Date: Page 1 Chief Complaint: (Please write reason, symptoms, condition or diagnosis that prompts your appointment) Past Medical History PERSONAL SKIN HISTORY YES NO Yes - Details Melanoma
More informationChange in Condition: When to report to the MD/NP/PA
Change in Condition: When to report to the MD/NP/PA Immediate Notification Any symptom, sign or apparent discomfort that is: Acute or Sudden in onset, and: A Marked Change (i.e. more severe) in relation
More informationPALS PRETEST. PALS Pretest
PALS PRETEST 1. A child with a fever, immune system compromise, poor perfusion and hypotension is most likely to be experiencing which type of shock A. cardiogenic B. Neurogenic C. Septic D. Hypovolemic
More informationA Perf-ect Differential
A Perf-ect Differential Carolyn Marcus, MD Disclosure of Financial Relationships Husband works as in-house legal counsel at Sanofi Case Presentation 6 year old boy with a history of constipation presents
More informationDATE OF BIRTH: MELANOMA INTAKE
MELANOMA INTAKE GENERAL INFORMATION How was your first diagnosed? (Check the diagnosis that describes your condition.) Melanoma Merkel Cell Carcinoma Squamous Cell Carcinoma Basal Cell Carcinoma Other
More informationIRB Approval From: 3/8/2010 To: 10/28/2010
UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM Phase II Study to Assess the Safety and Immunogenicity of an Inactivated Swine-Origin H1N1 Influenza Vaccine in HIV-1 (Version 3.0, 16 FEB 2010) IRB Approval From:
More informationGoPrivateMD General Information & History
Date: Date of Birth: Age: Sex: Male Female Address: City: State: Zip: Telephone: Email: PREFFERED PHARMACY NAME & LOCATION: PRIMARY PHYSICIAN: SPECIALISTS: INSURANCE GoPrivateMD will not bill your insurance.
More information1 I *********IF YOU ARE NOT ON ALLERGY SHOTS PLEASE SKIP THIS SECTION AND MOVE TO PAGE 2********* NAME: AGE: ---- ID (For Office Use Only):
NAME: AGE: ---- Date of Appointment:. ID (For Office Use Only): RETURN VISIT Date of Visit: Main Reason for visit: Reevaluation Family Doctor: Symptoms worse _ New problem _ Yearly follow up _ Follow up/office
More informationNursing Process Focus: Patients Receiving Dextran 40 (Gentran 40)
Assess for presence/history of hypovolemia, shock, venous thrombosis. Assess vital signs: Hypovolemic shock secondary to surgery, burns, hemorrhage, other serious condition PT and PTT abnormalities Venous
More informationCENTRAL CARE POLICY SYMPTOMS OF ILLNESS. Policy: Consumers will be observed for symptoms of physical problems, distress, pain, or unusual behaviors.
Page 1 of 5 CENTRAL CARE POLICY SYMPTOMS OF ILLNESS SUBJECT: SYMPTOMS OF ILLNESS ANNUAL REVIEW MONTH: June RESPONSIBLE FOR REVIEW: Director of Central Care LAST REVISION DATE: June 2009 Policy: Consumers
More informationWynne Huang, M.D. Family Medicine
PATIENT INFORMATION Last Name: First Name: Middle Initial: Date of Birth: SS#: - - Address: City, State, Zip Code Single( ) Married( ) Partner( ) Divorced( ) Widowed( ) Legally Separated( ) Male( ) Female(
More informationSupplementary Appendix
Supplementary Appendix This appendix has been provided by the authors to give readers additional information about their work. Supplement to: Jain S, Kamimoto L, Bramley AM, et al. Hospitalized patients
More informationPatient Name Date of Birth Page 1 of 6
2545 W. Hillcrest Dr. #205 Thousand Oaks, CA 91320 Admissions: 888.822.8938 Fax: 805.273.5246 Dear Medical Professional, This patient is seeking care to address eating disorder behaviors. For the patient
More informationFor the Patient: LUAVPEM
For the Patient: LUAVPEM Other Names: Second-Line Treatment Of Advanced Non- Small Cell Lung Cancer (NSCLC) With Pemetrexed LU = LUng AV = AdVanced PEM = PEMetrexed ABOUT THIS MEDICATION What is this drug
More informationMET Mobile Emergency Triage
MET Mobile Emergency Triage Saving Lives. Saving Dollars. Poznań University of Technology, Poland University of Ottawa, Canada CHEO (Childrens Hospital of Eastern Ontario), Canada What Triage Means? A
More informationMyeloma Haematology and Transplant Unit MPT
MPT Myeloma Haematology and Transplant Unit MPT This leaflet is offered as a guide to you and your family. The possible benefits of treatment vary; for some people chemotherapy may reduce the risk of the
More informationEmergency Department Suite
Emergency Department Suite This suite of Pediatric Learning Solutions (PLS) online courseware and curriculums provides 24/7 access to the foundational knowledge and just-in-time job aids clinicians working
More informationQuick review of Assessment. Pediatric Medical Assessment Review And Case Studies. Past Medical History. S.A.M.P.L.E. History is a great start.
EMS Live at Night January 12 th, 2010 Pediatric Medical Assessment Review And Case Studies Brian Rogge RN Northwest Medstar Pediatric/Perinatal Team Quick review of Assessment S.A.M.P.L.E. History is a
More informationMcHenry Western Lake County EMS System CE for Paramedics, EMT-B and PHRN s Sepsis Patients. November/December 2017
McHenry Western Lake County EMS System CE for Paramedics, EMT-B and PHRN s Sepsis Patients November/December 2017 This month we are going to take a look at the patient with Sepsis. Webster s defines septic
More informationMISSOURI SPINE INSTITUTE John D. Spears, D.O.
MISSOURI SPINE INSTITUTE John D. Spears, D.O. : / / Patient Name: Office Use Only Right/Left Handed BP: / Pulse: Height: Weight: BMI: Primary Care Physician: Cardiologist: of Birth: / / Age: Sex: M F Please
More informationT- Timing- concise vs. complete and thorough, depending on need of presenter and audience. E- Elicit- ask for feedback- more information needed? Less?
Review of STAGE presentation framework (from umass.macy.edu, revised Alicia Monroe, MD from 2005 STFM) S- style organization, sequencing adequate to build a case for your diagnosis or a story T- Timing-
More informationSeptic Shock. Kathryn Sims, PGY I
Septic Shock Kathryn Sims, PGY I A 6 y.o. previously healthy boy presents to the ED with 7 days of fever accompanied by chills. Further history reveals the patient has also been experiencing dysuria for
More informationMedical History Form
Medical History Form Name: ; Birth date: / / ; Date: / / Person filling out form: ; Relationship: Thank you for taking the time to fill out this valuable information. This allows us to provide the best
More informationNORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C.
NORTHERN VIRGINIA PULMONARY AND CRITICAL CARE ASSOCIATES, P.C. Past Medical History AIDS/HIV disease Anemia Asthma Bronchitis Cancer Date of last Chest X-ray Diabetes Mellitus, Type I Diabetes Mellitus,
More information