EPIC MACROS

MACRO DOTPHRASE	TEXT INSERTED
.NWHEDDOCTRANSFERS	“The patient has been medically stabilized. With reasonable clinical confidence, no material deterioration of this patient’s condition is likely to result from or occur during transfer. As patient is under care of Department of Corrections physicians, for continuity of care will arrange for transfer to {Recieving Facility:41766} for further evaluation and treatment.”
.NWHEDBEHAVHEALTHPEDSADOLFOLLOWUP	“Please contact the Northwell Child and Adolescent Behavioral Health Outpatient Practice at Mount Kisco for follow-up. 914-561-3774 Open Monday-Friday 930am-530pm 657 East Main St. Suite 2, Mount Kisco Most insurances accepted. Accepting patients ages 5 to 21. Bilingual Spanish clinicians and language interpretation services available.”
.NWHEDMD	I have personally evaluated and examined the patient.
.NWHEDMDACP	I shared this evaluation with the APP. I reviewed and verified the documentation.  I personally made/approved the management plan and take responsibility for the patient management.
.NWHEDMDRESIDENT	I was the supervising physician.  I have personally seen and examined this patient.  I have fully participated in the care of this patient.  I have made amendments to the documentation where appropriate and otherwise agree with the history, physical exam, and plan as documented by the resident.
.NWHEDPECARN	GCS 15. No confusion, agitation, slowness to respond or otherwise altered mental status. No LOC, no vomiting, no severe mechanism of injury. While headache is present, it is not described as severe. There are no objective neurologic deficits on exam. By PECARN evaluation tool, patient does not meet criteria for CT imaging at this time. In this clinical context, risk of clinically important TBI is <0.05%, which is generally lower than risk of CT-induced malignancies. Parents express agreement with plan.
.NWHEDPIT	I as the Triage provider was present during nursing triage/intake. Based on chief complaint and triage assessment, orders were placed in the EMR.  Patient will be brought back to room and full assessment by ED physician/ACP to follow.
.NWHEDROS	see HPI.  All other systems reviewed and are negative except as noted.
.NWHEDACP	I have personally evaluated and examined the patient. The attending was available to me as a supervising provider as needed.
.NWHEDama The patient decided against further medical evaluation and treatment and chose to sign out against medical advice.  It was explained to the patient that the Emergency Department evaluation and treatment plan were not complete and that signing out against medical advice was not advisable.  The risks of leaving the ED, including death and disability, were explained to the patient in detail, as well as the benefits of remaining in the Emergency Department for further evaluation.  In the physician’s opinion, the patient had the capacity to understand these risks and benefits.  The patient was given an AMA form to sign documenting this conversation.  The patient was encouraged to return to the Emergency Department at any time and was given detailed discharge instructions that included recommendations for follow-up.
.NWHEDbackpain The patient show no signs of neurological dyfunction, infection, or vascular compromise. There is no indication for imaging at this time as there was no direct trauma. I explained my physical exam findings to the patient who verbalizes understanding of plan to treat with medication and follow up with Orthopedics. They verbalize understanding and are comfortable with discharge at this time.
.NWHEDCHAIRPE	General: well appearing, no apparent distress, non-toxic Head: normocephalic, no trauma noted Eyes: non-icteric Mouth: handling secretions without difficulty Ext: no cyanosis, no peripheral edema Skin: nl turgor, no rash Neuro: non-focal and without acute deficit, moves all four extremities Psych: nl affect, nl mood
.NWHEDcmbed Based on patients on going issues with deconditioning and generalized weakness secondary to patients diagnosis of ———————- ———. Patient will require a semi electric hospital bed. This is necessary to achieve positioning of the body in ways not feasible with an ordinary bed. Or (requires positioning of the body in ways not attainable in an ordinary bed to alleviate pain.) or ( Patient requires the head of the bed elevated 30 degrees or more.) Patient requires frequent body changes and an immediate need for a change in body position which requires assistance. Bed pillows and wedges have been tried and ruled out. Patient or caregiver has ability to safely operate the semi electric hospital bed.
.NWHEDwalker Patient will require a rolling walker due to (DIAGNOSIS) for discharge.
.NWHEDwalker Patient will require a rolling walker due to (DIAGNOSIS) for discharge.
.NWHEDDC	Please follow up with your regular doctor. Continue taking all your medications as prescribed. Discuss with your doctor your visit to the emergency department and bring a copy of all your results with you. If you were giving any new prescriptions, please review the package insert for the full list of the medication’s side effects. Return to the ED if:
.NWHEDddxcp acute coronary syndrome aortic dissection pulmonary embolism pneumothorax pneumonia pericardial tamponade myocarditis / pericarditis esophageal rupture
.NWHEDddxlgib bleeding internal hemorrhoid diverticular bleeding arteriovenous malformation colon cancer brisk upper GI bleed
.NWHEDddxllq -diverticulitis – colitis – ovarian torsion – testicular torsion – kidney stone
.NWHEDddxrlq appendicitis ovarian torsion testicular torsion kidney stone right sided diverticular disease inflammatory bowel disease (uc/chrons)
.NWHEDddxruq gallstones	cholecystitis pancreatitis biliary obstruction gerd gastritis peptic ulcer disease

.NWHEDddxugib

bleeding peptic ulcer

gastritis

esophagitis

boerhaave syndrome

hemoptysis

.NWHEDendorse

Patient care turned over to Dr. [], pending diagnostics, re-evaluation, and disposition. Pertinent information reviewed and discussed.

.NWHEDeyeexam

EYE: PERRLA, cornea clear, no hyphema, no subconjunctival hemorrhage, no lid edema or erythema, no stain pickup, no foreign body on lid eversion,

SLIT LAMP: no foreign body, no dendritic lesions, no stain pick up

.NWHEDflupedsdc

Call your Pediatrician’s office tomorrow to inform them of the positive Flu test result.

Contact the child’s preschool or daycare (if applicable) tomorrow to inform them of the positive Flu test result.

Take Tylenol and Motrin for fever relief as directed on the package label.

Drink plenty of fluids to stay hydrated.

Rest.

Follow up right away or return to the emergency department if you are unable to keep anything down because of vomiting or there are other symptoms that concern you.

.NWHEDneckexam

Neck: supple, no meningismus, no midline c-spine tenderess

.NWHEDneuroexam

Cranial nerves II through XII grossly intact.  Motor/sensation/coordination grossly intact.

.NWHEDnormalpe

General: well appearing, no apparent distress

Head: normocephalic, no trauma noted

Eyes: non-icteric

Mouth: mucous membranes moist, handling secretions without difficulty

Neck: supple, no meningismus

Chest: non-tender

Cardiac: regular rate and rhythm, no murmurs noted

Pulmonary: no tachypnea, no retractions, no respiratory distress, breath sounds equal B/L, no rales, no wheezing, good air movement

Abdomen: soft, non-tender, non-distended

Ext: no cyanosis, no peripheral edema

Skin: nl turgor, no rash

Neuro: non-focal and without acute deficit, moves all four extremities

Psych: nl affect, nl mood

.NWHEDnormalpedpe

General: well appearing, no apparent distress, non-toxic, playful and interactive

Head: normocephalic, no trauma noted

Eyes: non-icteric

Mouth: mucous membranes moist, handling secretions without difficulty, Post oro: no exudate, no erythema

Ears: TMs nl b/l

Neck: supple, no meningismus

Chest: non-tender

Cardiac: regular rate and rhythm, no murmurs noted

Pulmonary: no tachypnea, no retractions, no respiratory distress, breath sounds equal B/L, no rales, no wheezing, good air movement

Abdomen: soft, non-tender, non-distended

Ext: no cyanosis, 2+ cap refill

Skin: nl turgor, no rash

.NWHEDnotsepsis

Clinically, this patient’s presentation was not consistent with sepsis.

.NWHEDacphelp

***, participated in the evaluation, management and treatment of this patient. I reviewed the history, examined the patient and performed the MDM and discussed the management with the patient and the practitioner

.NWHEDpe

General: Non-toxic appearing, patient in no acute distress

Head: Normocephalic, atraumatic

Eyes: No conjunctival injection or pallor, no scleral icterus, EOMI

Mouth: Mucous membranes moist

Neck: Supple, no meningismus

Chest: Non-tender

Cardiac: Regular rate and rhythm, no murmurs, rubs or gallops, distal pulses strong and symmetric

Pulmonary: Breathing unlabored, lungs clear to auscultation bilaterally without wheezes, rales or rhonchi

Abdomen: Soft, non-tender, non-distended, no guarding or rebound

Back: No CVA tenderness bilaterally, no vertebral tenderness

Ext: No extremity deformities, no lower extremity warmth, erythema, edema, tenderness

Skin: Normal color, normal turgor, no rash

Neuro: No focal neuro deficits.  Moves all extremities equally.

.NWHEDpedschairexam

General: well appearing, no apparent distress, non-toxic, playful and interactive

Head: normocephalic, no trauma noted

Eyes: non-icteric

Mouth: mucous membranes moist, handling secretions without difficulty

Ext: no cyanosis

Skin: no rash

Neuro: non-focal and without acute deficit, age appropriate, moves all four extremities

.NWHEDpsychdc

Upon reassessment, the patient has no acute medical needs and appears psychiatrically stable and appropriate for discharge. The patient does not appear to present a threat of harm to self or others.  Moreover, the patient’s current presentation is not attributable to an acute psychiatric illness that would necessitate immediate inpatient psychiatric treatment. The patient is currently calm and cooperative and at baseline.  I discussed discharge instructions and indications to return to the Emergency Department.

.NWHEDptstable

The patient has been examined and any medical condition has been stabilized. With reasonable clinical confidence, no material deterioration of this patient’s condition is likely to result from or occur during transfer.

.NWHEDptunstable

The patient has been examined, an Emergency Medical Condition (EMC) has been identified, and patient is not stable. However, transfer is medically indicated and in the best interest of the patient.

.NWHEDfollowoutpatient

For assistance with scheduling a doctor’s appointment with primary or specialty care, please contact the local Northwell Navigation Team at 914.418.2273. You may also contact the Residency Medical Practice in Chappaqua for a range of essential healthcare services at 914.458.8730.  

.NWHEDreferralcoordinator

We have provided your information to our Referrals Coordinator to assist with scheduling follow-up care after your visit to our Emergency Department. Our referrals coordinator will reach out to you at your indicated contact in 1-2 business days to discuss scheduling.

Should you wish to receive additional assistance or wish to reach out directly, our Referrals Coordinator can be reached at 914.242.8317, Mon-Fri/9a-5p.

.NWHEDsmoke

I discussed smoking cessation with the patient for 5 minutes but the patient declines any help with cessation at this time. Patient verbalizes understanding of the health risks associated with smoking.

.NWHEDthrombolytic

The risks, benefits, alternatives, and potential complications of thrombolytic (including bleeding in the brain or other parts of the body, allergic reaction, and/or even death) were discussed. We believe the benefits of IV thrombolytic outweigh the risks of the drug.  Through shared decision making, the patient (and/or patient’s agent or surrogate) expressed understanding and agree with plan to treat potential stroke with thrombolytic. Patient (and/or patient’s agent or surrogate) informed of potential for stroke mimics.  An opportunity to ask questions and have them answered was provided.