Active Allergies:
{'{{IF ALL_AFTER("LIST")=="" AND OBSANY("NKA")<>"T" AND OBSANY("NKA")<>"F"
THEN "Allergies have not been documented for this patient" ELSE IF ALL_AFTER("LIST")=="" AND OBSANY("NKA")=="" THEN "Allergies have not been documented for this patient" ELSE IF OBSANY("NKA") == "T" AND ALL_AFTER("LIST")=="" THEN "No Known Allergies" ELSE IF ALL_AFTER("LIST")<>"" THEN ALL_AFTER ("LIST") + "" ENDIF ENDIF ENDIF ENDIF}}'}

*Source: Tim Ward RN, Clinical Information Services Director, NORTHEAST CARDIOLOGY ASSOCIATES, Bangor, Maine 04401

AMIODARONE MONITORING CHECKLIST - Except as noted, none of the following were seen as problematic today:

1. Heart rate and rhythm
2. Thyroid function tests
3. Liver enzymes
4. Edema of the hands, feet
5. Weight loss
6. Pulmonary toxicity (PFTs)
7. Hypotension
8. Abnormal gait/ataxia, poor coordination, peripheral neuropathy,impaired memory
9. Dizziness, fatigue, headache, malaise
10. Involuntary movement, insomnia, sleep disturbances, tremor
11. Photosensitivity
12. Worsening CHF

Attending Physician Secure Email Reply:

Take one by mouth twice daily, morning and evening.

Instructions for adjusting (or maintaining) current warfarin (Coumadin®) dose were given and understanding verified while the patient was in the office.

Test Strip Lot #:
Exp. Date (yyyy-mm):
Operator: {USER.REALNAME}
Date/Time: {DATETIMESTAMP()}
CPT Code: 85610

Source: Covey S: 7 Habits of Highly Effective Families)

To remove ear wax and prevent reaccumulation, the following is recommended weekly:

1. To soften wax, with ear pointed up, pour 1/2-capful of 3% hydrogen peroxide into ear canal

2. Maintain position for 5 minutes (will bubble)

3. Tip head to allow peroxide to drain

4. Rinse with water (bulb syringe or shower)

5. To remove excess water, pour 1/2-capful of 70% isopropyl alcohol into the ear for 5 SECONDS

6. Drain and allow to dry

7. Repeat for the other ear

For this patient who is starting a statin medication, I have ordered a hepatic panel monthly x 3 months, followed by every 3 months for the first year, then every 6 months as long as a statin medication is being taken.

Patient Instructions: Continue current dosing schedule and instructions.
Recheck INR in: 4 weeks
How notified: Face-to-face Phone discussion Voice message E-mail Postal mail
Notified By: {USER.REALNAME}; {DATETIMESTAMP()}

Potassium-rich Foods

Sweet potato, 1 cup, baked, 950 milligrams (mg)
Acorn squash, 1 cup, cubed, 896 mg
Papaya, 1 medium, 781 mg
Dried apricots, 1/3 cup, 734 mg
Baked potato, 1 medium, 610 mg
Pinto beans, 1 cup, 583 mg
Spinach, 1 cup, cooked, 574 mg
Tomato juice, 8 ounces (oz.), 556 mg Blackstrap molasses, 1 tablespoon, 498 mg Orange juice, 8 oz., 496 mg
Cantaloupe, 1 cup, balls, 473 mg
Chocolate milk, low fat, 1 cup, 425 mg Banana, 1 medium, 422 mg

Persistent hyponatremia. Consider conditions with:

1. High ADH: True or effective volume depletion (diuretics, CHF, cirrhosis), hypothyroidism, hypoadrenalism, SIADH

2. Suppressed ADH: advanced renal failure, primary polydipsia

3. Pseudohyponatremia: hyperglycemia, hyperlipidemia, hyperproteinemia

Dx Plan:

Comp & hepatic panels, fasting lipids, am cortisol, TSH, free T4, spot plasma & urine osmolality, PO intake and Urine output diary

Rx Plan: Consider holding diuretics; fluid restriction

Narcotic Treatment Plan:

1. The condition for which narcotics have been prescribed:

2. Anticipated duration of narcotic therapy:

3. Response to narcotic to-date:

4. The current Rx is expected to last until:

5. Renew narcotic Rx when the current Rx & reflls run out?

(If YES, an appointment should be made before Rx is due to run out)

6. Return to the clinic:

The Framingham 10 YR CHD Risk Estimate for this patient = {OBSNOW("CHD 10YR RSK")}

2004 Revised NCEP Guideline for LDL Goal (mg/dL):

LDL <100 if High-Risk: CVD or DM or >1 risk factor + >20% 10 yr risk)

LDL <70 optional if VERY High Risk: CVD + multiple or severe/poorly controlled risks or Metabolic Syndrome X

LDL <130 or <100 if Moderately High-Risk: 10-20% 10-yr risk

CRITERIA FOR POSITIVE PPD (induration):

5 mm: recent close contact, abnl CXR, HIV+, immunosuppressed)

10 mm: recent immigrants; IVDA; workers-labs, NH, prison, homeless; DM, silicosis, CRF, cancer, kids, wt loss

15 mm: no specific risk factors

Current Problems:
{PROB_AFTER('LIST','com')}

NOTE: This adds not only the problem/Dx from the problem list, but also any comments recorded in the comments field, which can be very helpful!

Take one by mouth daily

Take one by mouth four times daily, morning, noon, early evening and bedtime.

Thanks. I noticed the resident's name was added as PC resident, which is not true for this patient. "PC Resident" appears in the patient banner so others can tell quickly which patients have a resident vs. attending as PCP. If a resident's name is added to this field, staff could assume this is the resident's patient, adding work, costs, and confusion.

My purpose here is not to be critical, but to improve the system and decrease errors. Please call if questions. Thanks.

{MEDS_PRIOR()}

STUDENT NOTE: {USER.REALNAME}

CC:

HPI:

UPDATES:

Past, Fam, Soc Hx:

Meds:

Health Maint:

ROS:

General:

Endocrine:

Skin:

HEENT:

Resp:

Cardiovasc:

GI:

GU:

Musc/skel:

Neuro:

Psych:

Heme/lymph:

PHYSICAL EXAM

General:

Skin:

HEENT:

Neck:

Nodes:

Resp:

Breast:

Cardiac:

Abdo:

Genital:

Rectal:

Musc/skel:

Neuro:

Psych:

LAB REVIEW:

ASSESSMENT:

PLAN:

Dx:

Rx:

Signed by:

ATTENDING PHYSICIAN NOTE

(Check one):

__ Patient seen & examined with resident
__Case discussed with resident at time of visit

The resident's Hx & exam as documented today were reviewed.

HPI, ROS and Past/Family/Soc Hx are significant for:

On my examination (if done), I find:

Key Dx tests show/indicate:

I confirm/revise the resident's Dx & assessment as:

I agree/revise the resident's plan as follows:

See resident's note for complete details of service.

Teaching Physician Note:

I saw and examined the patient with the resident and agree with the resident's findings and documented plan of care.

....................{USER.REALNAME}, {DATETIMESTAMP()}

Teaching Physician Note:

I saw and examined the patient with the student, confirmed and/or edited findings as documented above, and agree with the resultant documented findings and plan of care.

....................{USER.REALNAME}, {DATETIMESTAMP()}

I have reviewed with the resident the patient's medical history, the resident's findings on physical examination, the patient's diagnosis and treatment plan (including records of tests and therapies) and agree with the patient's care as documented by the resident.

Take one by mouth 3 times daily, morning, afternoon and evening.

This should be a 99204 visit, please adjust if needed

This should be a 99205 visit, please adjust if needed.

This should be a 99213 visit, please adjust if needed.

This should be a 99214 visit, please adjust if needed.

This should be a 99215 visit, please adjust if needed.

Attending Physician Note

Discussed and recommended several books:

Covey: 7 Habits of Highly Effective Families

Burns: Feeling Good

Carson: Taming your Gremlin

Peck: The Road Less Traveled

Hendrix: Getting the Love you Want: A Guide for Couples

Lerner: Dance of (Anger, Intimacy, Connection)

Chapman: 5 Love Languages

Breathnach: Simple Abundance Series

Elium: Raising a Son

Cermak: Time to Heal: The Road to Recovery for Adult Children of Alcoholics

posterior lymphoid hypertrophy ("cobblestoning")

Discussed 10 Cognitive Distortions that Contribute to Depression:

1. All-Or-Nothing Thinking
2. Overgeneralization
3. Negative Mental Filter
4. Disqualifying The Positive
5. Jumping To Conclusions
A. Mind Reading
B. Fortune Teller Error
6. Magnification (Catastrophizing) Or Minimization
7. Emotional Reasoning
8. Should Statements
9. Labeling And Mislabeling
10. Personalization

(Burns MD, David: Feeling Good-The New Mood Therapy, Avon, 1980, pp 42-3)

Please adjust Coumadin dose per protocol.

Homocysteine level continues >9.5 in patient with (or at risk of) CAD, The patient's homocysteine level is increased despite folic acid at 400 mcg per day.

Will increase folic acid to 1000 mcg, add vitamin B12 at 1000 mcg per day, and vitamin B6 (pyridoxine) 50 mg/d.

Repeat homocysteine level in one month.

Nurse Visit Supervising Physician Comments:

Otherwise observe for now. Call if worse or not better.

Please set up 40 min appt for the patient to see me for preop exam within 30 days of expected procedure.