Sample Note for AWS Comprehend Medical

gistfile1.txt

ROS (10 systems)
In addition to that documented in the HPI above, the additional ROS was obtained:
Constitutional: Denies fevers or chills
Eyes: Denies vision changes
ENMT: Denies sore throat
CV: Denies chest pain
Resp: Denies SOB
GI: Denies vomiting or diarrhea
GU: Denies painful urination
MSK: Denies recent trauma
Skin: Denies new rashes
Neuro: Denies new numbness or tingling or weakness
Endocrine: Denies unexpected weight loss
Heme: Denies bleeding disorders
 
ROS (6 systems)
In addition to that documented in the HPI above, the additional ROS was obtained:
Constitutional: Denies fevers or chills
Eyes: Denies vision changes
ENMT: Denies sore throat
CV: Denies chest pain
Resp: Denies SOB
GI: Denies vomiting or diarrhea

I have reviewed the triage vital signs.
Const: Well nourished, well developed, appears stated age
Eyes: PERRL, no conjunctival injection
HENT: NCAT, Neck supple without meningismus 
CV: RRR, Warm, well-perfused extremities
RESP: CTAB, Unlabored respiratory effort
GI: soft, non-tender, non-distended, no masses
MSK: No gross deformities appreciated
Skin: Warm, dry. No rashes
Neuro: Alert, CNs II-XII grossly intact. Sensation and motor function of extremities grossly intact.
Psych: Appropriate mood and affect.

TRAUMA EXAM
Vital signs
GENERAL: On backboard with C-collar in place.
SKIN: Warm and well perfused. No rashes, bruises, discolorations or abrasions.
HEAD: Atraumatic, normocephalic without edema, discoloration or evidence of trauma. Facial bones without deformities or tenderness. 
EYES: PERRL. No scleral icterus or conjunctival injection. Extraocular muscles intact without nystagmus or diplopia. No proptosis or enophthalmos.
EARS: Normal appearing pinnae. No hemotympanum.
NOSE: No discharge, tenderness, laxity. No nasal septal hematoma.
MOUTH: No malocclusion or trismus. Moist mucus membranes without blood. Posterior pharynx without erythema or exudate.
NECK: Trachea midline. No discolorations or edema. Neck immobilized in cervical collar.
CV: Regular rate and rhythm, Normal s1 and s2. No murmurs, rubs, or gallops.
PV: Radial pulses 2+ bilaterally and symmetric. Dorsalis pedis pulses 2+ bilaterally and symmetric. 2+ capillary refill. No extremity edema.
CHEST: No abrasions or ecchymosis. Chest symmetric with respirations. No chest wall tenderness. No crepitus. No step offs. Lungs are clear to auscultation bilaterally. No rales, rhonchi, wheezing or stridor.
ABDOMEN: No ecchymosis or abrasions. Soft, nondistended, nontender. Bowel tones normoactive. No masses or organomegaly.
BACK: No abrasions, skin openings, or ecchymosis. Spine without bony tenderness, no step offs.
PELVIC: Pelvis stable, nontender to lateral compression and palpation of symphysis pubis.
RECTAL: Normal tone. Stool without gross blood.
GU: Normal external genitalia without blood at meatus. No ecchymosis or edema.
MSK: No gross deformities or discolorations or lesions. Tolerates full range of motion of extremities without tenderness. 
NEURO: Alert and oriented to person, place, and time. GCS 15. CN II-XII intact. Sensation grossly intact. Strength 5/5 in bilateral UE and LE. Finger to nose intact bilaterally.

Symmetrically palpable radial and ulnar pulses. Capillary refill <2 seconds to all digits.
Intact sensation to light touch of the radial, median and ulnar nerves demonstrated by testing in the dorsal web space of the thumb, the distal palmar aspect of the index finger, and the lateral surface of the fifth finger.
2 point discrimination intact to 5mm (up to 6mm can be normal in digits 3-5) of discrimination in the affected digit.
Intact motor function of the radial, median and ulnar nerves demonstrated by strength of extension of the isolated distal joint of the index finger, hand grip, and spreading of the 2nd through 5th digits. Intact recurrent median nerve as demonstrated by ability to move thumb fully through opposition, abduction and flexion.
No snuffbox tenderness.



HMC/UWMC ED Sample Dot Phrase Templates
Version June 2017
Contact UW EM Chiefs with questions ([email protected])
9/6/17

GENERAL CONCEPTS OF DOCUMENTATION IN EM AT HMC/UWMC

There are different documentation requirements for different levels of billing (level 1 billing reflects lowest level of complexity/physician time/involvement; level 5 represents highest level of complexity/time/involvement).
 
HPI –
Level 1-3 (one element)
Level 4-5 (four elements)
 
ROS – (Please do not use the word “points” when describing)
Level 1 – not required
Level 2-3 – one system (not required if problem pertinent +/- documented in HPI)
Level 4 – 2 systems
Level 5 – 10+ systems 

Physical Exam
Level 1 – one system
Level 2-3 – 2 systems
Level 4 – 5 systems
Level 5 – 8 systems
 
High Acuity caveat documentation-- it is acceptable to use these phrases when appropriate if you are unable to complete portions of the HPI or PE:
unable to obtain history due to …
unable to perform full exam due to … (crashed to OR, Cath lab, etc)
 
Please tailor your specific ROS and Physical Exam documentation to reflect exactly what you asked / did/ saw! 

As part of your MDM, please include the differential diagnoses that you considered.

MDM coding is based on -
Number of diagnosis and management options
Chart reviewed (indicate in MDM that records/chart reviewed and notable for/summarized as follows….)
Risk
 


SAMPLE ROS DOT PHRASES 

Example statements for ROS (pick whichever systems you actually reviewed):
3/14 Review of Systems completed and negative except as stated above in the HPI (Systems reviewed: Resp, CV, GI)
 
10/14 Review of Systems completed and negative except as stated above in the HPI (Systems reviewed: HENT, Eyes, Resp, CV, GI, GU, MSK, Skin, Neuro, Psych)

ROS (10 systems)
In addition to that documented in the HPI above, the additional ROS was obtained:
Constitutional: Denies fevers or chills
Eyes: Denies vision changes
ENMT: Denies sore throat
CV: Denies chest pain
Resp: Denies SOB
GI: Denies vomiting or diarrhea
GU: Denies painful urination
MSK: Denies recent trauma
Skin: Denies new rashes
Neuro: Denies new numbness or tingling or weakness
Endocrine: Denies unexpected weight loss
Heme: Denies bleeding disorders
 
ROS (6 systems)
In addition to that documented in the HPI above, the additional ROS was obtained:
Constitutional: Denies fevers or chills
Eyes: Denies vision changes
ENMT: Denies sore throat
CV: Denies chest pain
Resp: Denies SOB
GI: Denies vomiting or diarrhea


SAMPLE PHYSICAL EXAM TEMPLATE DOT PHRASES


Bare-bones Physical Exam - Add in your further exam findings:
[VS here]
I have reviewed the triage vital signs.
Const: Well nourished, well developed, appears stated age
Eyes: PERRL, no conjunctival injection
HENT: NCAT, Neck supple without meningismus 
CV: RRR, Warm, well-perfused extremities
RESP: CTAB, Unlabored respiratory effort
GI: soft, non-tender, non-distended, no masses
MSK: No gross deformities appreciated
Skin: Warm, dry. No rashes
Neuro: Alert, CNs II-XII grossly intact. Sensation and motor function of extremities grossly intact.
Psych: Appropriate mood and affect.


TRAUMA EXAM
Vital signs
GENERAL: On backboard with C-collar in place.
SKIN: Warm and well perfused. No rashes, bruises, discolorations or abrasions.
HEAD: Atraumatic, normocephalic without edema, discoloration or evidence of trauma. Facial bones without deformities or tenderness. 
EYES: PERRL. No scleral icterus or conjunctival injection. Extraocular muscles intact without nystagmus or diplopia. No proptosis or enophthalmos.
EARS: Normal appearing pinnae. No hemotympanum.
NOSE: No discharge, tenderness, laxity. No nasal septal hematoma.
MOUTH: No malocclusion or trismus. Moist mucus membranes without blood. Posterior pharynx without erythema or exudate.
NECK: Trachea midline. No discolorations or edema. Neck immobilized in cervical collar.
CV: Regular rate and rhythm, Normal s1 and s2. No murmurs, rubs, or gallops.
PV: Radial pulses 2+ bilaterally and symmetric. Dorsalis pedis pulses 2+ bilaterally and symmetric. 2+ capillary refill. No extremity edema.
CHEST: No abrasions or ecchymosis. Chest symmetric with respirations. No chest wall tenderness. No crepitus. No step offs. Lungs are clear to auscultation bilaterally. No rales, rhonchi, wheezing or stridor.
ABDOMEN: No ecchymosis or abrasions. Soft, nondistended, nontender. Bowel tones normoactive. No masses or organomegaly.
BACK: No abrasions, skin openings, or ecchymosis. Spine without bony tenderness, no step offs.
PELVIC: Pelvis stable, nontender to lateral compression and palpation of symphysis pubis.
RECTAL: Normal tone. Stool without gross blood.
GU: Normal external genitalia without blood at meatus. No ecchymosis or edema.
MSK: No gross deformities or discolorations or lesions. Tolerates full range of motion of extremities without tenderness. 
NEURO: Alert and oriented to person, place, and time. GCS 15. CN II-XII intact. Sensation grossly intact. Strength 5/5 in bilateral UE and LE. Finger to nose intact bilaterally.

 
INFANT EXAM
Vitals
Constitutional: (location of infant), NAD, active, vigorous
EYES: PERRL. Sclera non-icteric. Conjunctiva non-injected. No discharge.
HENT: NCAT. Fontanelles flat. MMM. TMs clear bilaterally No cervical LAD.  Neck supple without meningismus.
CV: RRR, no M/R/G
Resp: No increased WOB. CTAB.
GI: Normoactive bowel sounds. Soft, NT/ND, no masses or organomegaly appreciated.
GU: Normal external female anatomy OR circumcised/uncircumcised penis. Testes descended and appear to be non-tender bilaterally.
MSK: No gross deformities appreciated.
Neuro: Alert, age appropriate. Normal muscle tone. Moving all extremities.
Skin: No rashes.
 

CHILD EXAM
Vitals
Constitutional: Well developed, NAD
EYES: PERRL. Sclera non-icteric. Conjunctiva not injected. No discharge.
HENT: NCAT. MMM. Posterior oropharynx non-erythematous, no tonsillar exudates. TMs clear bilaterally, canals normal. No cervical LAD. Neck supple without meningismus.
CV: RRR, no M/R/G, 2+ pulses in distal radius and DP pulses equal bilaterally
Resp: No increased WOB. Lungs CTAB.
GI: Normoactive bowel sounds. Soft, NT/ND, no masses or organomegaly appreciated.
GU: Normal external female anatomy OR circumcised/uncircumcised penis. Testes descended and non-tender bilaterally.
MSK: No gross deformities appreciated.
Neuro: Alert, age appropriate. Normal muscle tone. Moving all extremities.
Skin: No rashes.
 
 
PSYCH/MENTAL STATUS EXAM
Appearance: Well kempt
Behavior: Calm, good eye contact, in no acute distress
Mood: (patient describes)
Affect: (blunted, pleasant, angry) Mood is (congruent/discongruent) with affect.
Speech: Appropriate rate, quantity and volume.
Thought process: Linear
Thought content: (what is on patient’s mind). Denies SI/HI.
Cognition: Normal
Insight: Good
Judgment: Good
 

HAND EXAM (detailed)
Symmetrically palpable radial and ulnar pulses. Capillary refill <2 seconds to all digits.
Intact sensation to light touch of the radial, median and ulnar nerves demonstrated by testing in the dorsal web space of the thumb, the distal palmar aspect of the index finger, and the lateral surface of the fifth finger.
2 point discrimination intact to 5mm (up to 6mm can be normal in digits 3-5) of discrimination in the affected digit.
Intact motor function of the radial, median and ulnar nerves demonstrated by strength of extension of the isolated distal joint of the index finger, hand grip, and spreading of the 2nd through 5th digits. Intact recurrent median nerve as demonstrated by ability to move thumb fully through opposition, abduction and flexion.
No snuffbox tenderness.
 

EYE EXAM (detailed)
Visual Acuity: OD 20/20; OS 20/20; (wearing glasses/contacts (finger counting, motion, light perception))
Visual Fields:OD intact x 4; OS intact x 4
Extraocular movements: OD intact w/o diplopia; OS intact w/o diplopia
Lids/Lashes/Lacrimal: OD no lesions; OS no lesions
Conjunctiva & Sclera: OD white and quiet; OS white and quiet
Cornea: OD no fluorescein uptake;OS no fluorescein uptake
Anterior chamber: OD deep and quiet; OS deep and quiet
Iris: OD round and reactive; OS round and reactive
Lens: OD clear; OS clear
Retina: OD sharp disc margins (unable to visualize); OS sharp disc margins (unable to visualize)
Intraocular pressure: OD ___; OS ____


Eye Exam (alternative layout)
Eye Exam:		Right		Left
External:		Normal		Normal
Slit Lamp Exam:
- Lids/Lashes		Normal		Normal
- Conjunctiva / sclera	White, quiet	White, quiet
- Cornea		Clear		Clear
- Anterior Chamber	Deep, quiet	Deep, quiet
- Iris			Normal		Normal
- Lens			Normal 	Normal
- Vitreous		Normal		Normal
 
Fundus:
- Disc			Normal		Normal
- Vessels		Normal		Normal
- Periphery		Normal		Normal
 
Visual Acuity:		_		_		Both: _	
 
Visual Fields:		_		_
Tonometry:		_		_
 
 
NEURO EXAM (detailed)
Mental status: A/Ox3
CN II-XII tested and intact.
Sensation intact to sharp/dull differentiation in all extremities.
Motor: Normal tone and bulk. No abnormal movements appreciated. No pronator drift. Strength tested and 5/5 in bilateral wrist flexion/extension, elbow flexion/extension, shoulder abduction, straight leg raise, knee flexion/extension, ankle dorsiflexion/plantarflexion. Patient ambulates with a steady gait.
Coordination: Finger to nose and heel to shin testing intact bilaterally.
Reflexes: Brachioradialis, biceps, and patellar reflexes WNL and symmetric bilaterally. Babinski with downgoing toes bilaterally.
 

RECTAL EXAM (for cauda equina – insert into adult exam):
Symmetric intact sharp/dull differentiation to both sides of perineum. Normal rectal tone. Stool/no stool in rectal vault.

 
PELVIC EXAM
External genitalia unremarkable.
Speculum exam with normal appearing whitish vaginal discharge.
Vaginal wall mucosa is unremarkable.
Cervix visualized and is unremarkable (closed in appearance without any protruding material).
Bimanual exam without cervical motion tenderness, adnexal tenderness or any masses appreciated.
(Swabs for testing for gonorrhea, chlamydia and wet prep were obtained.)
 

SAMPLE MDM TEMPLATES
 
SEPSIS RE-EVALUATION
Date:
Time:
BP:
HR:
 
CHRONIC PAIN MDM
“I discussed the patient's recurrent pain issues with @him@. This is the *** time @name@ has been evaluated in the emergency department for pain-related issues in the last ***. I emphasized that my training was in the treatment of acute pain, that @his@ physical exam here is quite reassuring, and that definitive treatment of chronic pain is not the role of the emergency department.
 
“@He@ exhibited the following behaviors known to be associated with addiction and pseudoaddiction:
 
***- inability to restrict medications or take them on an agreed-upon schedule
 
***- taking multiple medications together
 
***- doctor shopping
 
***- the use of nonprescribed psychoactive drugs in addition to prescribed medications
 
***- noncompliance with recommended nonopioid treatments or evaluations
 
***- a preoccupation with opioids
 
***- insistence on rapid-onset formulations and routes of administration
 
***- reports of allergy or no relief whatsoever by any nonopioid treatments
 
I compassionately explained to @name@ that I felt providing opiate medications from the emergency department was counterproductive in that this may cause or exacerbate tolerance, acute overdose, physiological or psychological dependence, or withdrawal. We discussed that opiate use in the management of chronic pain is best managed by a single practitioner, such as a primary care provider or a pain specialist. We discussed adjunctive therapies such as heat, ice, and exercise, as well as non-opiate medications such as acetaminophen, NSAIDs, antidepressants, gabapentin, and pregabalin.
 
I reiterated to @name@ that the most effective management of @his@ chronic pain involves a multimodal approach coordinated by @his@ primary care provider and often includes physical therapy, cognitive behavioral therapy, and referrals to practitioners such as anesthesiologists trained in chronic pain management.
 
SNUFFBOX TENDERNESS
The patient demonstrated a concerning amount of snuffbox tenderness on examination of their __ hand. XR obtained and is negative. However, due to concern for an occult scaphoid fracture, the patient was placed in a thumb spica splint and instructed to follow up with their PCP for repeat exam and radiography in 10-14 days. Discussed this concern with the patient and emphasized the importance of keeping the hand splinted and obtaining appropriate follow up.
 
ALCOHOL INTOXICATION
Patient presented with altered mental status, smelling of alcohol with documented history of alcohol dependence. They arrived afebrile, with stable vital signs. Bedside glucose check without evidence of severe derangement. No signs of trauma or other etiology of altered mental status on initial exam. Patient was monitored with serial exams for several hours while they cleared their alcohol and altered mental status. Repeat exam benign. Patient then demonstrated ability to ambulate safely, tolerated oral intake, and articulated a safe discharge plan. Discharged to self-care, with return precautions for any new or concerning symptoms.
 
DISCHARGE
Pt was discharged home/self-care.
Pt was discharged with the following prescriptions: _____.
Pt was provided written discharge instructions.  Additional verbal instructions were given and discussed with Pt including, but not limited to, _____. 
Pt was asked to return to the ED immediately for any new or concerning or if they worsen.
Pt was in agreement, endorsed understanding, and questions were answered.
Pt instructed to follow-up with ____(PCP/Specialist) within _____days.
 

SAMPLE FULL GENERAL ED NOTE TEMPLATE


ID/CC:
_
 
HISTORY OF PRESENT ILLNESS:
_
 
PAST MEDICAL HISTORY:
_
 
MEDICATIONS:

Medications from chart: 
[ *MEDS - Home ]
 
ALLERGIES: 
[ *Allergies List ]

FAMILY HISTORY:
_
 
SOCIAL HISTORY:
_
 
REVIEW OF SYSTEMS:
 
In addition to that documented in the HPI above, the additional ROS was obtained:
Constitutional: Denies fevers or chills
Eyes: Denies vision changes
ENMT: Denies sore throat
CV: Denies chest pain
Resp: Denies SOB
GI: Denies vomiting or diarrhea
GU: Denies painful urination
MSK: Denies recent trauma
Skin: Denies new rashes
Neuro: Denies new numbness or tingling or weakness
Endocrine: Denies unexpected weight loss
Heme: Denies bleeding disorders
 
 
PHYSICAL EXAM:
  *Vital Signs - SCCA 
I have reviewed the triage vital signs
Const: Well nourished, well developed, appears stated age
Eyes: PERRL, no conjunctival injection
HENT: NCAT, Neck supple without meningismus 
CV: RRR, Warm, well-perfused extremities
RESP: CTAB, Unlabored respiratory effort
GI: soft, non-tender, non-distended, no masses
MSK: No gross deformities appreciated
Skin: Warm, dry. No rashes
Neuro: Alert, CNs II-XII grossly intact. Sensation and motor function of extremities grossly intact.
Psych: Appropriate mood and affect.

EKG:
_
 
CONSULTS:
Time called: _

MDM:
_

DIAGNOSIS:
_

DISPOSITION:
_



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SAMPLE PROCEDURE NOTE TEMPLATES
 
PROCEDURE NOTE: INCISION AND DRAINAGE OF ABSCESS
Indication: Abscess
Operator: _
Indications, risks, and benefits explained to patient and verbal informed consent obtained.
Correct patient and procedure type was verified.
1) The patient was anesthetized using _ cc lidocaine 1% w/epinephrine 
2) Abscess Location: _ 
3) Abscess Size: _ 
4) Procedure description: _ 
5) Culture specimen(s) obtained and sent for testing? _ Yes _ No

A clean dressing was applied.
The patient tolerated the procedure with some discomfort.

 
PROCEDURE NOTE: LACERATION REPAIR
Indication: Laceration
Operator: _
Indications, risks, and benefits explained to patient and verbal informed consent obtained.
Laceration location & length: _
Anesthesia was performed with 1% lidocaine with epinephrine.
The wound was irrigated with _cc of NS under pressure.
The patient was prepped and draped in usual fashion.
Repair type:
_ Simple: repair involving routine debridement & decontamination, simple one layer closure, superficial tissues, sutures/staples/tissue adhesives, total length of several repairs in same code category.
_ Intermediate: closure of contaminated single layer wound, layer closure (e.g. SQ tissue, superficial fascia), removal foreign material (e.g. gravel, glass), routine debridement & decontamination, simple exploration nerves/blood vessels/tendons in wound.
_ Complex: creation of defect for repair such as scar removal, debridement complicated wounds/avulsions, more complicated than layered closure, simple exploration nerves/vessels/tendons in wound or vessel ligation in wound, undermining/stents/retention sutures.

Number and type of sutures placed: _


FAST exam
Indication: Blunt Abdominal Trauma
No FF in RUQ, LUQ, pericardial, or pelvic windows
Quality of imaging obtained: _
Interpretation: _
Attending Physician interpreting: _
[_] Images saved to hard drive and uploaded to digital archive

Focused Cardiac Ultrasound
Indication: _ Cardiac Arrest _ Other:
Qualitative assessment of cardiac performance: [_] Good [_] Fair [_] Poor [_] Standstill
Pericardial Effusion: _None
Cardiac Tamponade: _None evident
Quality of imaging obtained: _
Interpretation: _
Attending Physician interpreting: _
[_] Images saved to hard drive of ultrasound machine

Focused Soft Tissue Ultrasound
Indication: suspected cellulitis vs. abscess
Quality of imaging obtained: _
Interpretation: _
Attending Physician interpreting: _
[_] Images saved to hard drive and uploaded to digital archive


Focused 1st Trimester OB Ultrasound
Indication: _
The patient was positioned in standard fashion.
Findings:
Structures visualized:
_ Gestational sac
_ Yolk sac
_ Fetal pole
FHR: _ bpm
EGA: _ weeks by :[_] CRL [_] BPD [_] HC [_] FL
Other:_
Quality of imaging obtained: _
Interpretation: _
Attending Physician interpreting: _
[_] Images saved to hard drive and uploaded to digital archive


US-guided peripheral venous cannulation
Candidate vein examined with linear array probe - confirmed collapsibility, lack of pulsatility, and proper anatomic location. [_] Local anesthesia provided via infiltration of 1% lidocaine w/o epi
Using aseptic technique, IV catheter inserted with flash of blood noted, flow of venous blood confirmed. Flushes easily and without pain. No hematoma or complications noted. Patient tolerated well.
[_] Images saved to hard drive and uploaded to digital archive

General Abdominal US exam
Indication: Preprocedure ultrasound for paracentesis
RUQ- [_] +FF
Subxyphoid- [_] +FF
LUQ- [_] +FF
Pelvic- [_] +FF
Quality of imaging obtained: _
Interpretation: Large amount of free fluid. No clear evidence of bowel adhesions to abdominal wall
Attending Physician interpreting: _
[_] Images saved to hard drive and uploaded to digital archive

Thoracic Ultrasound
Exam Indication: preprocedure ultrasound evaluation for thoracentesis
Right hemithorax- [_] +FF
Left hemithorax- [_] +FF
Quality of imaging obtained: _
Interpretation: free fluid in the [_] Right [_] Left hemithorax. No clear evidence of pleural adhesions
Attending Physician interpreting: _
[_] Images saved to hard drive and uploaded to digital archive 

 
PROCEDURE NOTE: ARTHROCENTESIS - KNEE
Indication: (side) knee pain, concern for septic arthritis
Operator: _
Indications, risks, and benefits explained to patient and informed consent obtained.
The (side) knee was prepped with chlorhexadine, and sterile drapes were applied to the area. The skin and subcutaneous tissue was anesthetized with 1% lidocaine with epinephrine. An 18 gauge needle was then inserted lateral to the patella into the joint space, and fluid was aspirated. Approximately ___ mL of ____ fluid was obtained. The needle was removed and a dressing was placed over the site. The patient tolerated the procedure well.
 
 
PROCEDURE NOTE: DENTAL BLOCK
Indication: dental pain
Operator: 
Verbal consent obtained from patient.
A 22g needle was used to inject bupivacaine into the region of the ___inferior alveolar nerve (apical portion of the affected tooth).
Patient tolerated the procedure well.
 
 
PROCEDURE NOTE: FRACTURE REDUCTION & SPLINTING
Indication: _
Operator: _
Indications, risks, and benefits explained to patient and informed consent obtained. (Emergent procedure; unable to obtain consent.)
Pre-procedure neurovascular exam:
A time out was performed.
(Describe reduction)
Post procedure neurovascular exam:
The patient tolerated the procedure well.
 
 
PROCEDURE NOTE: PHYSICIAN PLACEMENT OF PERIPHERAL IV -EXTERNAL JUGULAR
Indication: difficult to access - nursing staff unable to secure PIV
Operator: 
Location: (side) External jugular vein
Pt provided verbal consent for IV
Usual prep with chlorhexidine
18g IV placed on first attempt. Flash noted, and catheter advanced smoothly into the vein.
NS saline flushed without resistance, witnessed swelling, or patient discomfort
IV secured with I-site and tegaderm
The patient tolerated the procedure well.
 
PROCEDURE NOTE: PHYSICIAN PLACEMENT OF ULTRASOUND GUIDED PERIPHERAL IV
Indication: difficult to access - nursing staff unable to secure PIV
Operator: _
Location: _
Pt provided verbal consent for IV
Static views used to identify the target vein
Usual prep with chlorhexidine
2cc 1% lidocaine local block to facilitate procedure
20g long IV placed on first attempt under dynamic US guidance. Dark red flash noted, and catheter advanced smoothly into the vein
NS saline flushed without resistance, witnessed swelling, or patient discomfort
IV secured with I-site and tegaderm
The patient tolerated the procedure well.
 

PROCEDURE NOTE: SHOULDER REDUCTION
Indication: (anterior/posterior) dislocation of (side) shoulder
Operator: _
Indications, risks, and benefits explained to patient and informed consent obtained.
Radiographs were obtained showing dislocation.
Pre procedure, patient had intact motor & sensation of median, radial and ulnar nerves, with intact sensation of axillary nerve.
Joint was reduced without anesthesia with return of normal alignment.
Post procedure, patient had intact motor & sensation of median, radial and ulnar nerves, with intact sensation of axillary nerve.
Patient was placed in a sling, and instructed to follow up with primary care within 1 week.
 
PROCEDURE NOTE: FINGER REDUCTION
Indication: (side, joint, finger dislocation)
Operator: _
Indications, risks, and benefits explained to patient and informed consent obtained.
Pre procedure, patient had intact 5mm two-point discrimination to the radial and ulnar aspect of the affected finger.
A digital block was performed with lidocaine.
The finger was reduced with traction, and was splinted in extension.
A post reduction sensory exam was not obtained due to the digital block. The patient was able to fully flex and extend the previously dislocated digit.
The finger was splinted, which they were instructed to wear for 4 days.
Post reduction XR was without evidence of fracture.
The patient tolerated the procedure well.