Tri-Service Workflow (TSWF) · Web viewThe glans is then liberated by thumb traction at the 3 and 9...

Well VisitsCOREAbbreviation: 2tfp-coreDescription:

( CDS //HPI Coding: addressing 3 or more chronic conditions OR 4 of the following meets requirement for 99214, 99204// //location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms// )

Core HPI: (free text)

2tfp-hpi

2tfp-ros-

2tfp-pe-

Abbreviation: 2tfp-ros-coreDescription:

Core ROS: ( CDS //Coding: meets requirement for 99214, 99204// ) Systemic: Fever: No YES:, Chills: No YES: , Recent weight loss: No YES: Head: Headache: No YES: Otolaryngeal: Earache: No YES:, Nasal discharge: No YES: , Nasal passage blockage (stuffiness): No YES: , Sore throat: No YES: Cardiovascular: Chest pain: No YES: , Chest discomfort: No YES: Pulmonary: Dyspnea: No YES: , Cough: No YES: Gastrointestinal: Nausea: No YES: , Vomiting: No YES: , Abdominal pain: No YES:, Bright red blood per rectum: No YES: , Diarrhea: No YES: , Constipation: No YES: Genitourinary: Urinary frequency: No YES:, Urinary urgency: No YES:, Dysuria: No YES: Musculoskeletal: Back pain: No YES: Neurological: Lightheadedness: No YES:

2tfp-pe-core-detailed

Abbreviation: 2tfp-pe-core-detailedDescription:

CORE DETAILED PE: ( CDS //Coding: meets requirement for 99214, 99204// ) Vital signs reviewed Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO:, Acute distress: No YES: Eyes: Conjunctiva abnormalities: No YES: , Eyelid abnormalities: No YES: , PERRLA PUPILS ABNORMAL: , Normal Pupil size: Yes NO: , Normal Sclera: Yes NO: Ears: Normal outer ear: Yes NO: , Normal auditory meatus: Yes NO: , Normal tympanic membranes bilaterally: Yes NO: Nose: Nasal deformity: No YES: , Nasal discharge: No YES:

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James Neville, 08/09/18,

Remove this?

Mouth/Throat: Lip abnormalities: No YES: , Buccal mucosa abnormalities: No YES: , Dental abnormalities: No YES: , Pharynx abnormalities: No YES: Neck: Normal appearance: Yes NO: , Tenderness: No YES: , Thyroid enlargement: No YES:

Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO:, Regular Rate and rhythm: Yes NO: , Murmurs: No YES: , Edema: No YES: Abdomen: Normal Bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: , Muscle guarding: No YES: Extremities: Edema: No YES: , Muscle tenderness: No YES: , Asymmetry: No YES: , Joint deformity: No YES: Normal Movement of extremities: Yes NO: MSK: Gait and station Normal: Yes NO: Skin: Skin lesions: No YES:

Well WomanAbbreviation: 2tfp-hpi-wh-wellwomanDescription:

GYN History: ( CDS http://tswf-mhs.com/stg/cds/129 ) - History of abuse: No YES:- DES exposure: No YES:- STD exposure: No YES:- Vaginitis: No YES:- Pelvic Inflammatory Disease: No YES:- History of abnormal Pap smear: No YES:- History of HPV infection: No YES:- History of abnormal Mammogram: No YES:

Sexual Activity/Pregnancy HX/Birth control: Menstrual History: Age of menarche: _ Periods are Regular: Yes NO: Bleeding lasts: (days) _ Premenopausal Postmenopausal without bleeding POSTMENOPAUSAL WITH BLEEDING:

2tfp-ros-wh-wellwoman

2tfp-pe-wh-wellwoman

Abbreviation: 2tfp-ros-wh-wellwomanDescription:

Well Woman ROS:- Severe menstrual pain: No YES:- Less menstrual bleeding: No YES:- Excess menstrual bleeding: No YES:- Bleeding between periods: No YES:- Urinary loss of control: No YES:- Breast symptoms: No YES:- Vaginal discharge: No YES:

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Tim Corcoran, 08/08/18,

Check on this with Scott L.


Should we add more detail as to where to add Birth Control? Under “Histories”, “Social”, “Add”, “Sexual”, “More”


What does this mean? THIS WILL BE REPLACED BY SCOTT L.

http://tswf-mhs.com/stg/cds/129

- Hematochezia: No YES:- Pelvic pain: No YES:- Pain with intercourse: No YES:

Abbreviation: 2tfp-pe-wh-wellwomanDescription:

Well Woman PE: Vital signs reviewed Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Neck: Normal Appearance: Yes NO:, Tenderness: No YES: , Thyroid enlargement: No YES: , Enlarged lymph Nodes: No YES: Lungs: Clear to auscultation: Yes NO:, Wheezing: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO:, Regular Rate and rhythm: Yes NO: , Murmurs: No YES: , Edema: No YES: Breasts: Right: Skin dimpling: No YES:, Abnormal secretion: No YES: , Lesions: No YES:, Masses: No YES: , Axillary lymph Node enlargement: No YES: Left: Skin dimpling: No YES:, Abnormal secretion: No YES: , Lesions: No YES:, Masses: No YES: , Axillary lymph Node enlargement: No YES: Abdomen: Normal Bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: , Muscle guarding: No YES: , Palpable Mass: No YES: Genitalia: Normal External genitalia: Yes NO: , Normal Vaginal mucosa: Yes NO:, Normal Vagina: Yes NO: , Vaginal vesicles: No YES:, Cystocele: No YES:, Vaginal discharge: No YES:, Vaginal tenderness: No YES: , Rectocele: No YES: PELVIC: Cervical discharge: No YES:, Cervical lesions: No YES:, Cervical motion tenderness: No YES:, Uterus present: Yes NO: , Normal Uterus position: Yes Not Applicable NO: , Uterine tenderness: No YES: Not Applicable , Uterine enlargement: No YES: Not Applicable , Tubal mass: No YES: , Adnexal tenderness: No YES: , IUD string: Not Applicable Visualized Not visualized: Pap Smear Sample Taken: cervical vaginal both cervical and vaginal , GC/Chlamydia sample taken: No YES: Rectal: Hemorrhoids: No YES:, Sphincter tone: Normal ABNORMAL: , Rectum: Normal ABNORMAL: , Rectal masses: No YES: Extremities: Edema: No YES: , Muscle tenderness: No YES: , Asymmetry: No YES: , Joint deformity: No YES: Normal Movement of extremities: Yes NO: MSK: Gait and station Normal: Yes NO: Skin: Skin lesions: No YES:

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RTIAbbreviation: 2tfp-rtiDescription:

RTI HPI:Pt presents with _ day history of respiratory tract symptoms which include the following: Fever: No YES: , Sore throat: No YES:, Nasal discharge: No YES:, Nasal blockage(stuffiness): No YES:, Sinus pressure: No YES:, Sinus pain: No YES:, Ear pain: No YES:, Shortness of breath: No YES:, NO cough DRY COUGH PRODUCTIVE COUGHPt has had sick contacts: No YES: Pt has had recent exposure to strep: No YES: Pt has had a recent course of antibiotics: No YES: Pt has recently taken OTC medications No YES:

RTI Review of systems (ROS) Head: Headache: No YES:Eyes: Eye discharge: No YES: Gastrointestinal: Vomiting: No YES: , Diarrhea: No YES: , Abdominal pain: No YES: , Normal appetite: Yes NO:Skin: Rash: No YES:

RTI PE: Vital signs reviewed: Yes NO: Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO:, In distress: No YES: Eyes: Conjunctival abnormalities: No YES: , Eyelid abnormalities: No YES: , PERRLA PUPILS ABNORMAL: , Normal Pupil size: Yes NO:, Normal Sclera: Yes NO:, Normal Extraocular movements: Yes NO: Right Ear: Normal outer ear: Yes NO: , Normal auditory meatus: Yes NO: , External canal discharge, redness or swelling: No YES: , Tympanic membrane clear: Yes NO: , Tympanic membrane Erythematous: No YES: , Tympanic membrane Edema: No YES: , Tympanic membrane Exudate: No YES: , Tympanic membrane Fluid: No YES: , Tympanic membrane Bulging: No YES:, Loss of TM landmarks: No YES:, Normal Light reflex: Yes NO: Left Ear: Normal outer ear: Yes NO: , Normal auditory meatus: Yes NO: , External canal discharge, redness or swelling: No YES: , Tympanic membrane clear: Yes NO: , Tympanic membrane Erythematous: No YES: , Tympanic membrane Edema: No YES: , Tympanic membrane Exudate: No YES: , Tympanic membrane Fluid: No YES: , Tympanic membrane Bulging: No YES:, Loss of TM landmarks: No YES:, Normal Light reflex: Yes NO: Nose: Nasal deformity: No YES: , Nasal discharge: No YES: , Mucosa moist MUCOSA DRY , Mucosal edema: No YES: Mouth/Throat: Lip abnormalities: No YES: , Buccal mucosa abnormalities: No YES: , Dental abnormalities: No YES: , Pharynx abnormalities: No YES: , Tonsillar enlargement: No YES: , Tonsillar erythema: No YES: , Tonsillar exudate: No YES:

Neck: Appearance Normal: Yes NO:, Supple: Yes NO: , Tenderness: No YES: , Thyroid enlargement: No YES: , Cervical lymph Nodes enlarged: No YES: , Submandibular lymph Node enlargement: No YES: , Postauricular lymph Node enlargement: No YES: , Supraclavicular lymph Node enlargement: No YES: Lungs: Clear to auscultation: Yes NO:, Wheezing: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO:, Regular Rate and rhythm: Yes NO: , Murmurs: No YES:

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Abdomen: Normal Bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: , Muscle guarding: No YES: , Palpable Mass: No YES: , Spleen enlargement: No YES: , Liver enlargement: No YES: Extremities: Edema: No YES: , Muscle tenderness: No YES: , Movement of extremities: Normal ABNORMAL: MSK: Gait and station Normal: Yes NO: Skin: Skin lesions: No YES:

_____________________________________________________________________________________

Abbreviation: 2tfp-hpi-rtiDescription:

RTI HPI:Pt presents with _ day history of respiratory tract symptoms which include the following: Fever: No YES: , Sore throat: No YES:, Nasal discharge: No YES:, Nasal blockage(stuffiness): No YES:, Sinus pressure: No YES:, Sinus pain: No YES:, Ear pain: No YES:, Shortness of breath: No YES:, NO cough DRY COUGH PRODUCTIVE COUGHPt has had sick contacts: No YES: Pt has had recent exposure to strep: No YES: Pt has had a recent course of antibiotics: No YES: Pt has recently taken OTC medications No YES:

2tfp-ros-rti

2tfp-pe-rti

Abbreviation: 2tfp-ros-rtiDescription:

RTI Review of systems (ROS) Head: Headache: No YES:Eyes: Eye discharge: No YES: Gastrointestinal: Vomiting: No YES: , Diarrhea: No YES: , Abdominal pain: No YES: , Normal appetite: Yes NO:Skin: Rash: No YES:

Abbreviation: 2tfp-pe-rtiDescription:

RTI PE: Vital signs reviewed: Yes NO: Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO:, In distress: No YES: Eyes: Conjunctival abnormalities: No YES: , Eyelid abnormalities: No YES: , PERRLA PUPILS ABNORMAL: , Normal Pupil size: Yes NO:, Normal Sclera: Yes NO:, Normal Extraocular movements: Yes NO: Right Ear: Normal outer ear: Yes NO: , Normal auditory meatus: Yes NO: , External canal discharge, redness or swelling: No YES: , Tympanic membrane clear: Yes NO: , Tympanic membrane Erythematous: No YES: , Tympanic membrane Edema: No YES: , Tympanic membrane Exudate: No YES: , Tympanic membrane Fluid: No YES: , Tympanic membrane Bulging: No YES:, Loss of TM landmarks: No YES:, Normal Light reflex: Yes NO:

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Left Ear: Normal outer ear: Yes NO: , Normal auditory meatus: Yes NO: , External canal discharge, redness or swelling: No YES: , Tympanic membrane clear: Yes NO: , Tympanic membrane Erythematous: No YES: , Tympanic membrane Edema: No YES: , Tympanic membrane Exudate: No YES: , Tympanic membrane Fluid: No YES: , Tympanic membrane Bulging: No YES:, Loss of TM landmarks: No YES:, Normal Light reflex: Yes NO: Nose: Nasal deformity: No YES: , Nasal discharge: No YES: , Mucosa moist MUCOSA DRY , Mucosal edema: No YES: Mouth/Throat: Lip abnormalities: No YES: , Buccal mucosa abnormalities: No YES: , Dental abnormalities: No YES: , Pharynx abnormalities: No YES: , Tonsillar enlargement: No YES: , Tonsillar erythema: No YES: , Tonsillar exudate: No YES:

Neck: Appearance Normal: Yes NO:, Supple: YES No: , Tenderness: No YES: , Thyroid enlargement: No YES: , Cervical lymph Nodes enlarged: No YES: , Submandibular lymph Node enlargement: No YES: , Postauricular lymph Node enlargement: No YES: , Supraclavicular lymph Node enlargement: No YES: Lungs: Clear to auscultation: Yes NO:, Wheezing: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO:, Regular Rate and rhythm: Yes NO: , Murmurs: No YES: Abdomen: Normal Bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: , Muscle guarding: No YES: , Palpable Mass: No YES: , Spleen enlargement: No YES: , Liver enlargement: No YES: Extremities: Edema: No YES: , Muscle tenderness: No YES: , Movement of extremities: Normal ABNORMAL: MSK: Gait and station Normal: Yes NO: Skin: Skin lesions: No YES:

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MetabolicDiabetesAbbreviation: 2tfp-hpi-met-diabetesDescription: Diabetes Specific HPI:Patient is on a reduced calorie diet plan: Yes NO:Patient is engaged in a behavioral modification plan: Yes NO: Patient engages in 150 minutes of moderate intensity exercise per week AND muscle strengthening activities 2 or more days per week: Yes NO: Home glucose monitoring records (Not required if stable on oral meds):_- Episodes with symptoms of hypoglycemia (shakiness, anxiety, sweating, irritability, etc.): No YES:- Episodes with symptoms of hyperglycemia (frequent urination, thirst, blurred vision, etc.): No YES:- Episodes with symptoms of ketoacidosis (confusion, abdominal pain, fruity breath, etc.): No YES:

2tfp-ros-met-diabetes

2tfp-pe-met-diabetes

Abbreviation: 2tfp-ros-met-diabetesDescription:

Diabetes Specific ROS: Eyes: Worsening vision: No YES: Otolaryngeal: Oral mucosa complaints: No YES: , Dental complaints: No YES: Cardiovascular: Intermittent leg claudication: No YES: , Leg is cold: No YES: , Foot is cold: No YES: Endocrine: Hair loss from lower limbs: No YES: Genitourinary: Change in urinary frequency: No YES: Musculoskeletal: Foot abnormality or sores : No YES: , Sexual dysfunction: No YES: Neurological: Leg weakness: No YES: , Tingling of the hands: No YES: ,Tingling of the feet: No YES: , Leg numbness: No YES: Skin: Lesions: No YES: , Bruising: No YES:, Skin thinning: No YES:

Abbreviation: 2tfp-pe-met-diabetesDescription:

Diabetes Specific PE: Vital signs reviewed Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO:, In distress: No YES: Neck: Appearance Normal: Yes NO:, Tenderness: No YES: , Thyroid enlargement: No YES: , enlarged lymph Nodes: No YES:

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Lungs: Clear to auscultation: Yes NO:, Wheezing: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO:, Regular Rate and rhythm: Yes NO: , Murmurs: No Yes: , Edema: No YES: , Normal dorsalis pedis pulses: Yes NO: Musculoskeletal: Interosseous atrophy of the hands: No YES: , Normal appearance of the feet: Yes NO: , Nail dystrophy observed: No YES:, Foot lesion or ulcer present: No YES: Neurological: Normal Patellar reflex: Yes NO:, Normal Achilles reflex: Yes NO: , Normal Monofilament test: Yes NO: , Normal Foot proprioception: Yes NO: , Normal Foot Vibration sensation: Yes NO: Skin: Skin lesions: No YES: , Abdominal stria: No YES: , Xanthoma: No YES:

ObesityAbbreviation: 2tfp-hpi-met-obesityDescription: Obesity Specific HPI: Assessment of patient’s readiness to change: precontemplation contemplation preparation action maintenancePatient is on a reduced calorie diet plan: Yes NO:Patient is engaged in a behavioral modification plan: Yes NO: Patient engages in 150 minutes of moderate intensity exercise per week AND muscle strengthening activities 2 or more days per week: Yes NO: Patient has had previous episodes of weight loss and gain: No YES:

2tfp-ros-met-obesity

2tfp-pe-met-obesity

Abbreviation: 2tfp-ros-met-obesityDescription:

Obesity Specific ROS: Eyes: Worsening vision: No YES: Otolaryngeal: Oral mucosa complaints: No YES: Cardiovascular: Chest pain: No YES: , Chest discomfort: No YES: , Intermittent leg claudication: No YES: , Leg is cold: No YES: , Foot is Not cold: No YES: Pulmonary: Dyspnea No YES: Endocrine: Hair loss from lower limbs: No YES: Genitourinary: Change in urinary frequency: No YES: Musculoskeletal: Foot abnormality or deformity : No YES: Neurological: Leg weakness: No YES: , Tingling of the hands: No YES: ,Tingling of the feet: No YES: , Leg numbness: No YES:

Abbreviation: 2tfp-pe-met-obesityDescription:

Obesity Specific PE: Vital signs reviewed.

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Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Neck: Appearance Normal: Yes NO:, Tenderness: No YES: , Thyroid enlargement: No YES: , enlarged lymph Nodes: No YES: Lungs: Clear to auscultation: Yes NO:, Wheezing: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO:, Regular Rate and rhythm: Yes NO: , Murmurs: No YES: , Edema: No YES: , Normal dorsalis pedis pulses: Yes NO: Musculoskeletal: Interosseous atrophy of the hands: No YES: , Normal appearance of the feet: Yes NO:, Normal movement of extremities Yes NO: Neurological: Normal patellar reflex: Yes NO:, Normal Achilles reflex: Yes NO: Skin: Skin lesions: No YES: , Abdominal stria: No YES: , Xanthoma: No YES:

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PulmonaryAsthma Initial EvaluationAbbreviation: 2tfp-hpi-pulm-asthma-initial Description:

Asthma HPIPt presents with _ day week month year history of respiratory symptoms which include the following:

Factors that correlate with onset:_, Frequency:_, Timing:_, What makes it better:_, What makes it worse:_

Current symptoms include: - Shortness of breath: No YES: - Cough: No YES: - Wheezing: No YES: - Dyspnea: No YES: - Chest tightness: No YES: - Chest pain: No YES:

History of: - Wheezing: Yes NO: - Shortness of breath: No YES: - Cough: No YES: - Dyspnea: No YES: - Chest tightness: No YES: - Chest pain: No YES: - Exposure to known allergens: No YES: - Onset is with exercise: No YES: - History of atopy: No YES:- Sputum production: No YES: - Symptoms awaken patient at night: No YES: - Symptoms change with the seasons: No YES:

2tfp-ros-pulm-asthma-initial

2tfp-pe-pulm-asthma-initial

Abbreviation: 2tfp-ros-pulm-asthma-initialDescription:

Asthma ROS: Systemic: Fever: No YES: Otolaryngeal: Earache: No YES:, Nasal discharge: No YES: , Nasal passage blockage (stuffiness): No YES: , Sore throat: No YES: Skin: Rash: No YES: Neurological: Lightheadedness: No YES: , Syncope: No YES:

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Abbreviation: 2tfp-pe-pulm-asthma-initialDescription:

Asthma PE: Vital signs reviewed Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Eyes: Normal conjunctiva: Yes NO: Ears: Normal outer ear: Yes NO: , Normal auditory meatus: Yes NO: , Normal tympanic membranes bilaterally: Yes NO: Nose: Nasal deformity: No YES: , Nasal discharge: No YES: , Nasal polyps: No YES: , Mucosal swelling: No YES: Mouth/Throat: Lip Normal: Yes NO: , Buccal mucosa Normal: Yes NO: , Pharynx Normal: Yes NO: Neck: Appearance Normal: Yes NO: , Tenderness: No YES: , Thyroid enlargement: No YES: , Lymphadenopathy: No YES: Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Normal respiratory depth and rhythm: Yes NO: Chest: Deformity: No YES: , Use of accessory muscles: No YES: CV: Normal heart sounds: Yes NO: , Regular rate and rhythm: Yes NO: , Murmurs: No YES: , Edema: No YES: , Normal radial pulse: Yes NO: Abdomen: Soft: Yes NO: , Mass(es): No YES: Skin: Rash: No YES: Extremities: Clubbing: No YES:

Asthma Follow upAbbreviation: 2tfp-hpi-pulm-asthma-followupDescription:

Asthma Follow-up HPIPt presents for follow up of asthma. Pt has a __month year history of asthma diagnosed by:_ Recent emergency room visits: No YES:- symptom frequency: 2 or less days per week more than 2 days a week but Not daily DAILY THROUGHOUT THE DAY- nighttime awakenings: 2 or less times a month 3-4 times per month MORE THAN ONCE PER WEEK, BUT NOT NIGHTLY OFTEN 7 TIMES PER WEEK- short-acting beta agonist use for symptom control: 2 or less days per week more than 2 days a week but not daily DAILY SEVERAL TIMES PER DAY- Interference with normal activity: None minor limitation SOME LIMITATION EXTREMELY LIMITED- Lung function: Normal FEV1 between exacerbations; FEV1>80% of predicted; FEV1/FVC Normal FEV1>or equal 80% of predicted; FEV1/FVC Normal FEV1>60% BUT <80% OF PREDICTED; FEV1/FVC REDUCED 5 % FEV1<60 % OF PREDICTED; FEV1/FVC REDUCED >5%-Exacerbations requiring oral systemic corticosteroids: 0-1 per year 2 or more a year

2tfp-ros-pulm-asthma-followup

2tfp-pe-pulm-asthma-followup

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Abbreviation: 2tfp-ros-pulm-asthma-followupDescription:

Asthma Follow-up ROS: Systemic: Fever: No YES: Otolaryngeal: Earache: No YES: , Nasal discharge: No YES: , Nasal passage blockage (stuffiness): No YES: , Sore throat: No YES: Skin: Rash: No YES: Neurological: Lightheadedness: No YES: , Syncope: No YES:

Abbreviation: 2tfp-pe-pulm-asthma-followupDescription:

Asthma Follow-up PE: (Duplicate 2tfp-pe-pulm-asthma-initial and change abbreviation to above)

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GIAGEAbbreviation: 2tfp-hpi-gi-ageDescription:

AGE HPIPt presents with _ day week month year history of gastrointestinal symptoms which include the following:-Vomiting: YES: No vomiting BILIOUS VOMITING: VOMITING WITH BLOOD: , able to keep down fluids UNABLE TO KEEP DOWN FLUIDS: , -Diarrhea: YES: NO diarrhea DIARRHEA WITH MUCOUS: DIARRHEA WITH BLOOD: DIARRHEA WITH BLOOD AND MUCOUS: -Abdominal pain: No YES: , Decreased urine output: No YES: , Decreased tearing: No YES: , Sunken Eyes: No YES: , Dry appearing lips and mouth: No YES: , Fever: No YES:

2tfp-ros-gi-age

2tfp-pe-gi-age

Abbreviation: 2tfp-ros-gi-ageDescription:

AGE ROS:Systemic: Chills: No YES: , Malaise: No YES: , Normal weight: Yes NO:Pulmonary: Dyspnea: No YES:Neurological: Change in alertness level: No YES:Musculoskeletal: Joint pain: No YES:Skin: Jaundice No YES:

Abbreviation: 2tfp-pe-gi-ageDescription:

AGE PE: Vital signs reviewed Gen Appearance: Alert: Yes NO: , Active: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Eyes: Conjunctiva moist: Yes NO: , Eyes Not sunken: Yes NO: Mouth/Throat: Lips Normal: Yes NO: , Buccal mucosa moist: Yes NO: , Pharynx Normal: Yes NO: Neck: Supple: Yes NO: Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Crackles: No YES: , Rhonchi: No YES: , Normal respiratory depth and rhythm: Yes NO: CV: Regular rate and rhythm: Yes NO: , Murmurs: No YES: , Radial pulses Normal: No YES: Abdomen: Normal bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: , Muscle guarding: No YES: , Spleen enlargement: No YES: , Liver enlargement: No YES:, Mass(es): No YES: Extremities: Capillary refill Normal: Yes NO: Skin: Normal skin temperature: Yes NO: , Mottling: No YES: , Skin turgor normal: Yes NO:

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Abdominal PainAbbreviation: 2tfp-hpi-gi-abdominalpainDescription:

Abdominal Pain Specific HPI:Pt presents with _ day week month year history of abdominal pain symptoms which include the following:

Location: Diffuse Localized:__ Quality: sharp dull aching cramping other: , constant intermittent migrates other: Frequency: constant intermittent other: What makes it better:_What makes it worse:_History: - Abdominal surgery: No YES: - Recent travel: No YES: - Alcohol use: No YES:Symptoms:- Nausea: No YES:- Vomiting: No YES: - Anorexia: No YES:- Constipation: No YES:- Diarrhea: No YES:- Pain radiates to the back: No YES: - Flank pain: No YES:- Blood in stool: No YES:- Black tarry stools: No YES:

2tfp-ros-gi-abdominalpain

2tfp-pe-gi-abdominalpain

Abbreviation: 2tfp-ros-gi-abdominalpainDescription:

Abdominal Pain ROS: ( CDS //Coding: meets requirement for 99214, 99204// ) Systemic: Fever: No YES: , Chills: No YES: , Recent weight loss: No YES: Head: Headache: No YES: , Sore throat: No YES: Cardiovascular: Chest pain: No YES: , Chest discomfort: No YES: Pulmonary: Dyspnea: No YES: , Cough: No YES: Genitourinary: Change in urinary frequency: No YES: , Feelings of urinary urgency: No YES: , Dysuria: No YES: , Hematuria: No YES: Musculoskeletal: Back pain: No YES: Neurological: Lightheadedness: No YES: Skin: Jaundice: No YES: Female Only: Vaginal discharge: No YES:

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Abbreviation: 2tfp-pe-gi-abdominalpainDescription:

Abdominal Pain PE: Vital signs reviewed Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: Yes NO: Eyes: Conjunctiva Normal: Yes NO: , Sclera Normal: Yes NO: Mouth/Throat: Lips Normal: Yes NO: , Buccal mucosa Normal: Yes NO: , Pharynx Normal: Yes NO: Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Normal respiratory depth and rhythm: Yes NO: CV: Normal heart sounds: Yes NO:, Regular rate and rhythm: Yes NO: , Murmurs: Yes NO: , Edema: No YES: Abdomen: Normal bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: , Muscle guarding: No YES: , Murphy’s sign: No YES: , Costovertebral angle tenderness: No YES: , Psoas sign: No YES: Female Only: Vaginal discharge: No YES: , Cervical discharge: No YES: , Mass(es): No YES: , Cervical motion tenderness: No YES:

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Shouldn’t the default answer be “YES”?


Shouldn’t the default answer be “YES”?

CVHypertensionAbbreviation: 2tfp-hpi-cv-hypertensionDescription: Hypertension Specific HPI:Pt presents for HTN F/U Pt presents for initial HTN evaluation appointmentPatient adherent with the DASH diet plan. Patient adherent with Mediterranean diet Patient is NOT adherent with Dash or Mediterranean diet plan. Patient engages in 150 minutes of moderate intensity exercise per week. Patient does NOT engage in 150 minutes of moderate intensity exercise per week.Patient uses self-monitoring device to track exercise. Pt does NOT use self-monitoring device to track exercise. -2tfp-ros-cv-hypertension -2tfp-pe-cv-hypertension Abbreviation: 2tfp-ros-cv-hypertensionDescription: Hypertension Specific ROS: Systemic: Fatigue: No YES:, Lightheadedness: No YES: , Daytime somnolence: No YES: , No change in weight RECENT WEIGHT LOSS: RECENT WEIGHT GAIN: Eyes: Change in vision: No YES: , Transient blindness: No YES: Head: Headache: No YES: Otolaryngeal: Snoring: No YES: Cardiovascular: Chest pain: No YES: , Claudication: No YES: , Tachycardia: No YES: Pulmonary: Cough: No YES: , Dyspnea: No YES: Gastrointestinal: Flank pain: No YES: Genitourinary: Sexual dysfunction: No YES: Musculoskeletal: Proximal weakness: No YES: Skin: Bruising: No YES: , Skin thinning: No YES:

Abbreviation: 2tfp-pe-cv-hypertensionDescription: Hypertension Specific PE: Vital signs reviewed: BP At Goal: No YES: Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO:, In distress: No YES: , Central obesity: No YES: Neck: Normal Appearance: Yes NO: , Tenderness: No YES: , Thyroid enlargement: No YES: , Carotid bruits: No YES: Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO: , Regular Rate and rhythm: Yes NO: , Murmurs: No YES: , Edema: No YES: Normal Dorsalis pedis pulse: Yes NO:

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Abdomen: Normal Bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: , Muscle guarding: No YES: , Palpable Mass: No YES: , Aortic bruit: No YES: , Renal bruit: No YES: Extremities: Edema: No YES: , Muscle tenderness: No YES: , Muscle weakness: No YES: , Normal Movement of extremities: Yes NO: MSK: Normal gait and station: Yes NO: Neurological: Normal patellar reflex: Yes NO: , Normal Achilles reflex: Yes NO: Skin: Skin lesions: No YES: , Abdominal Stria: No YES: , Xanthoma: No YES:

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DermRashAbbreviation: 2tfp-hpi-derm-rashDescription:

Rash Specific HPI:Pt presents with _ day week month year history of rash symptoms which include the following:Any treatments attempted: No YES:Description of rash:_Area of involvement:_, Factors at onset:_What makes it better:_, What makes it worse:_ - Pruritus: No YES:- Family history of atopy: No YES:- Exposures/travel: No YES:

2tfp-ros-derm-rash

2tfp-pe-derm-rash

Abbreviation: 2tfp-ros-derm-rashDescription: Rash Specific ROS/Red Flags: Systemic: Fever: No YES: , Recent infection: No YES: , Recent weight loss: No YES: , Fatigue: No YES: Other: History of cancer: No YES: , Chronic corticosteroid use: No YES:

Abbreviation: 2tfp-pe-derm-rashDescription:

Rash Specific PE: Vital signs reviewed Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Eyes: Conjunctiva Normal: Yes NO: , Eyelids Normal: Yes NO: , PERRL: Yes NO: , Sclera Normal: Yes NO: Mouth/Throat: Lips Normal: Yes NO: , Buccal mucosa Normal: Yes NO: , Pharynx Normal: Yes NO: CV: Normal heart sounds: Yes NO: , Regular rate and rhythm: Yes NO: , Murmur(s): No YES: , Edema: No YES: Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Normal respiratory depth and rhythm: Yes NO: Skin: Primary lesions present: macules and papules macules (1cm or less, flat) patches (>1cm flat) papules (5mm or less, raised) plaques (>5mm, raised) Nodules pustules vesicles wheals Distribution- central and peripheral central peripheral linear , symmetric asymmetric:

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Additional lesions: None excoriations scales crusts fissures scars erosions , distribution- central and peripheral central peripheral linear , symmetric asymmetric:

AcneAbbreviation: 2tfp-hpi-derm-acneDescription:

Acne Specific HPI:Pt presents with _ day week month year history of acne symptoms which include the following:Patient description of primary lesions:_, Initial site of rash:_, Current distribution:_, Factors that correlate with onset:_, What makes it better:_, What makes it worse:_- Any treatments attempted: No YES:- Response to any treatments: No YES: - Drug/medication exposure: No YES:- Caused by shaving: No YES:

2tfp-ros-derm-acne

2tfp-pe-derm-acne

Abbreviation: 2tfp-ros-derm-acneDescription: Acne Specific ROS/Red Flags: Systemic: Fever: No YES: Musculoskeletal Polyarthritis: No YES: Skin: Flushing: No YES:

Abbreviation: 2tfp-pe-derm-acneDescription:

Acne Specific PE: Vital signs reviewed Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Eyes: Conjunctiva Normal: Yes NO: , Eyelids Normal: Yes NO: , PERRL: Yes NO: , Sclera Normal: Yes NO: Skin:

Lesions present: Comedones: Yes NO: Inflammatory papules and pustules: No YES:MILD YES:MODERATE

YES:SEVERE Nodules: No YES:FEW YES:MULTIPLE

Distribution: Face: Yes NO:Neck: No YES:Back: No YES:

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Chest: No YES:Other: No YES:

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PsychInsomniaAbbreviation: 2t-fp-hpi-psych-insomnia Description:

Insomnia Specific HPI: (CDS https://sstg.ditaeon.com/cds/26 )

Pt presents with _ days weeks months years history of sleep disorder which include the following:What makes it better:_, What makes it worse:_Deployment Related No YES: History of Traumatic Brain Injury: No YES:Epworth Sleepiness Scale (ESS) Reviewed No YES: Score__ (CDS: Scores >9 Recommends Consultation)

Nature of sleep problem: -Falling asleep? No YES: -Staying asleep? No YES: -Waking in middle of night? No YES: -Waking too early in morning? No YES: -Nightmares? No YES: -Functional impairment: No YES:

Factors Correlated with Sleep Problems: -Environmental/Behavioral Factors Associated with Insomnia: No YES: -Does patient remain in bed when having difficulty sleeping? No YES: -Does patient read, watch t.v., or do other activities in bed? No YES: -Is bedroom environment conducive to sleep (quiet, dark, comfortable): Yes NO: -Physical exercise within 2 hours of going to bed? No YES: -Does patient worry in bed? No YES: -Caffeine use within 6 hours of going to bed? No YES: -Tobacco use within 2 hours of going to bed? No YES: -ETOH used to fall asleep? No YES: -OTCs, Prescription Medications used to fall asleep? No YES: Symptoms associated with Sleep Problems: -Snoring? No YES: -Waking with headache? No YES: -Other person has said patient gasps for breath at night? No YES: -Daytime napping? No YES:

Insomnia Specific ROS: Systemic: Heat/cold Intolerance: No YES: , Chills: No YES: , Recent Weight Loss: No YES: Eyes: Vision changes: No YES:

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https://sstg.ditaeon.com/cds/26

Neurological: Memory problems: No YES: , Sensory disturbances: No YES:, Motor disturbances: No YES: Psych: Anxiety Present: No YES: , Panic Attacks Present: No YES: , Racing Thoughts Present: No YES: , Pressured Speech Present: No YES: , Rapidly Changing Moods Present: No YES: , Hallucinations Present: No YES: , Delusions Present: No YES: , Nightmares Present: No YES: , Flashbacks Present: No YES: Skin: Hair loss or thinning No YES:

Insomnia PE: Vital signs reviewed Gen Appearance: Well appearing: Yes NO: , Well-Developed: Yes NO: , Well-Nourished: Yes NO: , In Acute distress: No YES: Neck: Normal Appearance: Yes NO: , Tenderness Present: No YES: , Thyroid Enlargement: No YES: CV: Normal Heart Sounds: Yes NO: , Regular Rate and Rhythm: Yes NO: , Murmurs: No YES: , Edema: No YES: Skin: Hair Thinning: No YES: , Pale Skin Present: No YES: Psych: Behavior: Appropriate: Yes NO:Psychomotor Retardation: No YES:Psychomotor Agitation: No YES: Speech: Normal Rate and Tone Yes NO: , Slowed: No YES: , Soft: No YES: , Pressure or Loud: No YES: , Affect: Depressed: No YES: , Euthymic: Yes NO: , Anxious: No YES: , Euphoric: No YES: , Irritable: No YES: , Flat No YES:Thought Processes: Linear Logical and Goal Directed: Yes NO: , Thought Blocking: No YES: , Tangential: No YES: , Racing Thoughts: No YES:Thought Content: Suicidal Ideation: No YES: , Homicidal Ideation: No YES:

Insomnia Specific Interventions:

[_] Provided education regarding biopsychosocial factors related to sleep [_] Discussed benefits of referral for specialty behavioral health care (IBHC) [_] Provided education on sleep hygiene [_] Provided education on stimulus control for improved sleep [_] Provided education and instruction on implementation of sleep restriction [_] Trained patient in relaxation techniques [_] Instructed patient in use of sleep diary [_] Pharmacotherapy

Depression-initialAbbreviation: 2tfp-hpi-psych-depression-initialDescription:

Depression Specific HPI:Pt presents with _ day week month year history of depression symptoms which include the following:Factors that correlate with onset:_, What makes it better:_, What makes it worse:_- Reviewed PHQ-9: Yes: NO:- CSSRS performed?: No YES:

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- Current symptoms are causing problems at work, school, home or in relationships No YES:- Prior episodes of depression: No YES:- Any treatments attempted: No YES:- Response to any treatments: No YES:- Current alcohol or drug use: No YES:- Family psychiatric history: No YES:- Current life stresses: No YES:

Abbreviation: 2tfp-ros-psych-depression-initialDescription:

Depression ROS: Systemic: Heat/cold Intolerance: No YES: , Chills: No YES: , Recent Weight Loss: No YES: , Eyes: Vision changes: No YES: Neurological: Memory problems: No YES: , Sensory disturbances: No YES: , Motor disturbances: No YES: Psych: Anxiety Present: No YES: , Panic Attacks Present: No YES: , Racing Thoughts Present: No YES: , Pressured Speech Present: No YES: , Rapidly Changing Moods Present: No YES: , Hallucinations Present: No YES: , Delusions Present: No YES: , Nightmares Present: No YES: , Flashbacks Present: No YES: Skin: Hair loss or thinning No YES:

Abbreviation: 2tfp-pe-psych-depression-initialDescription:

Depression PE: Vital signs reviewed Gen Appearance: Well appearing: Yes NO: , Well-Developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Neck: Normal Appearance: Yes NO: , Tenderness Present: No YES: , Thyroid Enlargement: No YES: CV: Normal Heart Sounds: Yes NO: , Regular Rate and Rhythm: Yes NO: , Murmurs: No YES: , Edema: No YES: Skin: Hair Thinning: No YES:, Pale Skin Present: No YES: Psych: Behavior: Appropriate: Yes NO:Psychomotor Retardation: No YES:Psychomotor Agitation: No YES: Speech: Normal Rate and Tone Yes NO: , Slowed: No YES: , Soft: No YES: , Pressure or Loud: No YES: , Affect: Depressed: No YES:, Euthymic: Yes NO: , Anxious: No YES:, Euphoric: No YES:, Irritable: No YES: , Flat No YES:Thought Processes: Linear Logical and Goal Directed: Yes NO: , Thought Blocking: No YES: , Tangential: No YES: , Racing Thoughts: No YES:Thought Content: Suicidal Ideation: No YES: , Homicidal Ideation: No YES:

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Depression-followupAbbreviation: 2tfp-hpi-psych-depression-followupDescription:

Depression Follow-up Specific HPI:Pt presents with _ day week month year history of depression symptoms which include the following:Factors that correlate with onset:_, What makes it better:_, What makes it worse:_- Reviewed PHQ-9: Yes: NO:- CSSRS performed? No YES:- Current symptoms are causing problems at work, school, home or in relationships: No YES:- Prior episodes of depression: No YES:- Any treatments attempted: No YES:- Response to any treatments: No YES:- Current alcohol or drug use: No YES:- Family psychiatric history: No YES:- Current life stresses: No YES:

-Current treatment:_-Response to treatment:_

2tfp-ros-psych-depression-followup

2tfp-pe-psych-depression-followup

Abbreviation: 2tfp-ros-psych-depression-followupDescription:

Depression Follow-up ROS: Systemic: Recent weight loss No YES:, Recent Weight Gain No YES: GI: Nausea: No YES: Neurological: Headache: No YES: Psych: Racing Thoughts: No YES: , Pressured speech: No YES: , Rapidly Changing Moods Present: No YES: GU: Sexual Dysfunction Present: No YES:

Abbreviation: 2tfp-pe-psych-depression-followupDescription:

Depression Follow-up PE: Vital signs reviewed Gen Appearance: Well appearing: Yes NO: , Well-Developed: Yes NO: , Well-Nourished: Yes NO: , In Distress: No YES: Psych: - Behavior: Appropriate No YES: , Psychomotor Retardation: No YES: , Psychomotor Agitation: No YES: ,- Speech: Normal Rate and Tone: No YES:, Slowed Soft: No YES:, Loud and Pressure: No YES: - Affect: Depressed: No YES: , Euthymic: No YES: , Anxious: No YES: , Euphoric: No YES: , Irritable: No YES: , Flat: No YES:

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- Thought processes: Linear logical and goal directed No YES: , Thought Blocking: No YES: , Tangential No YES: , Racing Thoughts: No YES: , Thought content: Suicidal Ideation: No YES: , Homicidal Ideation: No YES

Anxiety-initialAbbreviation: 2tfp-hpi-psych-anxiety-initialDescription:

Anxiety Specific HPI:Pt presents with _ day week month year history of anxiety symptoms which include the following:Factors that correlate with onset:_, What makes it better:_, What makes it worse:_- Reviewed GAD-7: Yes: NO:- Excessive worry or anxiety about 2 or more activities or events: No YES: - Muscle tension: No YES: - Easily fatigued: No YES: - Difficulty concentrating or mind going blank: No YES: - Sleep disturbance: No YES:- Any prior episodes of anxiety or panic: No YES: - Significant maladaptive change behavior related to panic attacks: No YES:- Any treatments attempted: No YES:- Response to any treatments: No YES: - Current alcohol or drug use: No YES: - Family psychiatric history: No YES: - Current life stresses: No YES:

2tfp-ros-psych-anxiety-initial

2tfp-pe-psych-anxiety-initial

Abbreviation: 2tfp-ros-psych-anxiety-initialDescription:

Anxiety ROS: Systemic: Hot flashes: No YES: , Recent Weight Loss: No Yes: Pulmonary: Shortness of breath: No YES: CV: Palpitations: No YES: Neurological: Seizures: No YES: , Sensory disturbances: No YES: , No Motor Disturbances: No YES: Psych: Depression: No YES: , Racing thoughts: No YES: , Pressured speech: No YES: , Rapidly Changing Moods: No YES: , Hallucinations Present: No YES: , Delusions Present: No YES: , Nightmares Present: No YES: , Flashbacks Present: No YES: Skin: Flushing Present: No YES:

Abbreviation: 2tfp-pe-psych-anxiety-initialDescription:

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Anxiety PE: Vital signs reviewed: Yes NO: Gen Appearance: Well appearing: Yes NO: , Well-Developed: Yes NO: , Well-Nourished: Yes NO: , In distress No YES: Neck: Abnormal Appearance: No YES: , Tenderness No YES: , Thyroid enlargement No YES: CV: Abnormal heart sounds: No YES: , Regular rate and rhythm: Yes NO: , Murmurs: No YES: , Edema Present: No YES: Skin: Abnormal Temperature No YES: Psych: -Behavior: Appropriate: No YES: , Psychomotor Retardation: No YES: , Psychomotor Agitation: No YES: ,-Speech Normal Rate and Tone: No YES: , Slowed Soft: No YES: , Loud and Pressure: No YES: -Affect: Depressed No YES: , Euthymic No YES: , Anxious No YES: , Euphoric No YES: , Irritable No YES: , Flat No YES:-Thought processes: Linear logical and goal directed No YES: , Thought Blocking No YES: , Tangential No YES: , Racing Thoughts No YES:-Thought content: Suicidal Ideation No YES: , Homicidal Ideation No YES:

Anxiety-followupAbbreviation: 2tfp-hpi-psych-anxiety-followupDescription:

Anxiety Follow-up Specific HPI:Pt presents with _ day week month year history of Anxiety symptoms which include the following:- Current treatment:_- Response to treatment:_- Excessive worry or anxiety about 2 or more activities or events No YES:- Worry is difficult to control No YES:- Restlessness No YES:- Feeling keyed up or on edge No YES: - Muscle Tension No YES:- Easily fatigued No YES:- Difficulty concentrating or mind going blank No YES: - Irritability No YES:- Recurrent or unexpected panic attacks No YES:- Persistent concern or worry about additional panic attacks or the consequences of No YES: - Significant maladaptive change behavior related to panic attacks No YES:

-Current treatment:_-Response to treatment:_

2tfp-ros-psych-anxiety-followup

2tfp-pe-psych-anxiety-followup

Abbreviation: 2tfp-ros-psych-anxiety-followup

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Description:

Anxiety Follow-up ROS: Systemic: Recent Weight Loss No YES: , Recent Weight Gain No YES: GI: Nausea Present No YES: Neurological: Headache Present No YES: Psych: Racing Thoughts Present No YES: , Pressured Speech Present No YES: , Rapidly Changing Moods No YES: GU: Sexual Dysfunction Present No YES:

Abbreviation: 2tfp-pe-psych-anxiety-followupDescription:

Anxiety Follow-up PE: Vital signs reviewed Gen Appearance: Well appearing Yes NO: , Well-Developed Yes NO: , Well-Nourished Yes NO: , In distress No YES:Psych: - Behavior: Appropriate No YES: , Psychomotor Retardation No YES: , Psychomotor Agitation No YES:- Speech Normal Rate and Tone No YES: , Slowed Soft No YES: , Loud and Pressure No YES: - Affect: Depressed No YES: , Euthymic No YES: , Anxious No YES: , Euphoric No YES: , Irritable No YES: , Flat No YES:- Thought processes: Linear logical and goal directed No YES: , Thought Blocking No YES: , Tangential No YES: , Racing Thoughts No YES: , - Thought content: Suicidal Ideation No YES: , Homicidal Ideation No YES:

ADHD-initial Abbreviation: 2tfp-hpi-psych-adhd-initialDescription: ADHD Initial HPI

Patient presents for evaluation of attention problems that have been present for the past _ months years.

Child is experiencing the following:Academic Failure: No YES:Reduced ability to pay attention: No YES:Hyperactive behavior: No YES:Peer relationship problems: No YES:Socially inappropriate/disruptive behavior: No YES:Other: No YES:

Cardiac Screening: ( CDS //Instructions: any positive responses should be added to the patient’s history or family history// ) -Does the patient have a Cardiac History: No YES:

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-Family cardiac history:History of early sudden deaths: No YES:History of hypertrophic cardiomyopathy: No YES : History of arrhythmias: No YES:History of prolonged QT syndrome: No YES:

PREVIOUS ADHD History: ( CDS //Instructions: copy and paste these into comments section of the diagnosis for ADD so they can be tracked// )Age at diagnosis:_Age started meds:_Medications previously tried:_History of counseling:_Other therapies:_IEP:_

ADHD ROSPalpitations: No YES:Chest Pain: No YES:Syncope: No YES:Headache: No YES:Emotional Lability: No YES:Tics: No YES:Abdominal Pain: No YES:Decrease in Appetite: No YES:Recent unintentional weight loss: No YES:Trouble falling asleep: No YES:Sleep disturbances: No YES:

ADHD PE:

Vital signs reviewed Gen Appearance: Well appearing: Yes NO: , Well-Developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Neck: Normal appearance: Yes NO: , Tenderness Present: No YES: , Thyroid Enlargement Present: No YES: CV: Abnormal Heart Sounds: No YES: , Regular rate and rhythm: Yes NO: , Murmurs: No YES: , Edema Present: No YES: Skin: Abnormal Temperature Present: No YES: Psych: Psychomotor Agitation: No YES: , Speech: Abnormal Normal Rate and Tone No YES: , Slowed/Soft: No YES: , Pressure and Loud: No YES: , Affect: Depressed No YES:, Euthymic: No YES: , Anxious: No YES: , Euphoric: No YES: , Irritable: No YES: , Flat: No YES: , Thought processes: Non-linear logical and Non-goal directed No YES: , Thought Blocking: No YES: ,

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Tangential Thoughts: No YES:, Racing Thought: No YES: , Thought content: Suicidal Ideation: No YES: , Homicidal Ideation: No YES:

Testing / Diagnostics

ADHD-Vanderbilt Rating Scale: (CDS https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf

YES No : Vanderbilt Assessment Scale indicated and given to parent(s) to be completed by parent(s) and teachers

ADHD-Vanderbilt Rating Scale Summary: (CDS Scoring Instructions pg.10 https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf)Total number of questions scored 2 or 3 in questions 1–9:__Total number of questions scored 2 or 3 in questions 10–18:__ Total Symptom Score for questions 1–18:__Total number of questions scored 2 or 3 in questions 19–28:__ Total number of questions scored 2 or 3 in questions 29–35:__Total number of questions scored 4 or 5 in questions 36–43:__Average Performance Score:__

Chronic Care Plan

Target Symptoms for ADHD

Home: __ School: __ Social: _____________________________________________________________________________________

ADHD follow-up

Abbreviation: 2tfp-hpi-psych-adhd-followupDescription: ADHD Follow-up HPI

Patient presents for f/u for ADHD ADD that has been present for the past _ years months. Pt has been treated with: medication therapy medication and therapy and symptoms are: stable improving worsening.

Child is experiencing the following:Academic Failure: No YES:Reduced ability to pay attention: No YES:Hyperactive behavior: No YES:Peer relationship problems: No YES:Socially inappropriate/disruptive behavior: No YES:Other: No YES:

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ADHD ROSPalpitations: No YES:Chest Pain: No YES:Syncope: No YES:Headache: No YES:Emotional Lability: No YES:Tics: No YES:Abdominal Pain: No YES:Decrease in Appetite: No YES:Recent unintentional weight loss: No YES:Trouble falling asleep: No YES:Sleep disturbances: No YES:

ADHD PE:

Vital signs reviewed Gen Appearance: Well appearing: Yes NO: , Well-Developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: CV: Abnormal Heart Sounds: No YES: , Regular rate and rhythm: Normal ABNORMAL: , Murmurs: No YES: , Edema Present: No YES: Skin: Abnormal Temperature Present: No YES: Psych: Psychomotor Agitation: No YES: , Speech: Abnormal Normal Rate and Tone No YES: , Slowed/Soft: No YES: , Pressure and Loud: No YES: , Affect: Depressed No YES:, Euthymic: No YES: , Anxious: No YES: , Euphoric: No YES: , Irritable: No YES: , Flat: No YES: , Thought processes: Non-linear logical and Non-goal directed No YES: , Thought Blocking: No YES: , Tangential Thoughts: No YES:, Racing Thought: No YES: , Thought content: Suicidal Ideation: No YES: , Homicidal Ideation: No YES:

Follow-up Testing / Diagnostics

ADHD-Vanderbilt Follow-up Rating Scale: (CDS https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf )YES No: Vanderbilt Assessment Follow-up Scale returned and reviewed

ADHD-Vanderbilt Rating Scale Follow-up Summary: (CDS Scoring Instructions pg.10 https://www.nichq.org/sites/default/files/resource-file/NICHQ_Vanderbilt_Assessment_Scales.pdf)Total Symptom Score for questions 1–18: __Average Performance Score for questions 19–26:__

Chronic Care Plan

Target Symptoms for ADHD

Home: __

School: __

Social: __

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NeuroHeadacheAbbreviation: 2tfp-hpi-neuro-headacheDescription:

Headache Specific HPI:Pt presents with _ day week month year history of headache symptoms which include the following:

Current Severity: 0 1 2 3 4 5 6 7 8 9 10 /10Location: bilateral unilateral left unilateral right orbital/supraorbital temporal other: , Quality: sharp dull aching throbbing/pounding other: , constant intermittent migrates other: , Factors that correlate with onset:_, Frequency:_, Average Level:_, Worst Level:_, Least Level:_, What makes it better:_, What makes it worse:_Other history- Associated with aura: No YES:- Treatments attempted for this headache: No YES:- Disabling from work or Normal activities: No YES:- History of previous episodes of headache: No YES:- History of previous treatments: No YES:- Response to previous treatments: No YES:

Red Flags:- “Worst headache of life”: No YES:- Head or neck trauma: No YES:- Fever, systemic illness or rash: No YES:- Sudden onset/maximal intensity within seconds/minutes, “thunderclap” headache: No YES:- Triggered by cough/exertion/exercise/Valsalva: No YES:- Focal neurological signs: No YES:- New onset headache after age 50: No YES:- Seizures: No YES:- Progressive worsening over weeks/months: No YES:- Change in personality/mental status/consciousness: No YES:

2tfp-ros-neuro-headache

2tfp-pe-neuro-headache

Abbreviation: 2tfp-ros-neuro-headacheDescription:

Headache ROS: Systemic: Fever: No YES: , Chills: No YES: , Recent weight loss: No YES: Head: Scalp tenderness: No YES: Eyes: Photophobia: No YES: , Conjunctival injection: No YES: , Tearing: No YES: , Eyelid edema: No YES: , Miosis/ptosis: No YES: Otolaryngeal: Phonophobia: No YES: , Nasal discharge: No YES: , Nasal passage blockage (stuffiness): No YES: , Fullness in ear: No YES: , Sinus pain: No YES: Neck: Stiff neck: No YES: , Pain radiating to neck: No YES:

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Neurological: Restlessness: No YES: 2tfp-pe-neuro-headache

Abbreviation: 2tfp-pe-neuro-headacheDescription:

Headache PE: Vital signs reviewed Gen Appearance: Alert: Yes NO: , Active: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , In distress: No YES: Head: Scalp Nontender: Yes NO: Eyes: Conjunctiva moist: Yes NO: , Periorbital edema: No YES: Ears: Discharge: No YES: Neck: Supple: Yes NO: , Tenderness: No YES: , Normal range of motion: Yes NO: Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Crackles: No YES: , Rhonchi: No YES: , Normal Respiratory depth and rhythm: YES NO: CV: Normal Heart sounds: Yes NO: , Regular Rate and rhythm: Yes NO: , Murmurs: No YES: MSK: Normal gross motor strength: Yes NO: Neuro: Cranial 2-12 nerves intact: Yes NO: , Normal Deep tendon reflexes: Yes NO: , Sensation grossly normal: Yes NO: Skin: Rash: No YES: Psych: Memory Normal: Yes NO:

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EndocrineHypothyroidAbbreviation: 2tfp-hpi-endo-hypothyroidDescription:

Hypothyroid HPIPt presents with _ day week month year history of symptoms which include the following:

- Fatigue/tiredness: No YES:- Lethargy: No YES:- Proximal muscle weakness: No YES:- Weight gain: No YES:- Poor concentration: No YES:- Constipation: No YES:- Cold intolerance: No YES:- Dry skin: No YES:- Hair loss or thinning: No YES:

2tfp-ros-endo-hypothyroid

2tfp-pe-endo-hypothyroid

Abbreviation: 2tfp-ros-endo-hypothyroidDescription:

Hypothyroid ROS:CV: Swelling: No YES:Musculoskeletal: Muscle pain: No YES:Psych: Depression: No YES: , Memory impairment: No YES:

Abbreviation: 2tfp-pe-endo-hypothyroidDescription:

Hypothyroid PE: Vital signs reviewed. Gen Appearance: Alert: Yes NO: , Active: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: Eyes: Conjunctiva moist: Yes NO: , Periorbital edema: No YES: Mouth/Throat: Buccal mucosa moist: Yes NO: , Normal Pharynx: Yes NO: Neck: Supple: Yes NO: , Tenderness: No YES: , Normal Thyroid: Yes NO: Lungs: Clear to auscultation: Yes NO: , Wheezing: No YES: , Crackles: No YES: , Rhonchi: No YES: , Normal Respiratory depth and rhythm: Yes NO: CV: Normal Heart sounds: Yes NO: , Regular Rate and rhythm: Yes NO: , Murmurs: No YES: ,Normal Radial pulses: Yes NO: Abdomen: Bowel sounds: Yes NO: , Soft: Yes NO: , Tenderness: No YES: ,

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Muscle guarding: No YES: , Splenic enlargement: No YES: , Liver enlargement No YES: , Mass/es present: No YES: Extremities: Normal Capillary refill: Yes NO: MSK: Muscle tenderness: No YES: Neuro: Normal Deep tendon reflexes: Yes NO: Skin: Skin temperature: Normal COOL SKIN COLD SKIN , Rash: No YES:

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MSKLBPAbbreviation: 2tfp-hpi-msk-lbpDescription:

LBP Specific HPI:Pt presents with _ day week month year history of lower back pain symptoms which include the following:Location:_, Quality:_, Distribution of symptoms:_ When do symptoms occur:_ Factors that correlate with onset:_,Pain: Average Level:_, Worst Level:_, Lowest Level:_What makes it better:_, What makes it worse:_- Sensory or motor deficit: No YES:- Functional deficit(s): No YES:- History of previous episodes of back pain: No YES:- History of previous treatments: No YES:- Response to previous treatments: No YES:

2tfp-ros-msk-lbp

2tfp-pe-msk-lbp

Abbreviation: 2tfp-ros-msk-lbpDescription:

LBP Specific ROS/Red Flags:

ROS: - Psychological factors/stress present: No YES:

LBP Red FlagsFever: No YES:Recent infection: No YES:IV drug use: No YES:Fatigue: No YES:Immunosuppression: No YES:Loss of bowel or bladder control: No YES:Osteoporosis: No YES:Wide based gait: No YES:Saddle anesthesia: No YES:Focal neurological deficit: No YES:Recent significant trauma: No YES:History of cancer: No YES:Recent weight loss: No YES:Chronic corticosteroid use: No YES:AGE >70: No YES:Duration >1 month despite appropriate treatment: No YES:

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2tfp-pe-msk-lbp 2tfp-ros-msk-lbp

2tfp-pe-msk-lbp

Abbreviation: 2tfp-ros-msk-lbpDescrLBP Specific ROS/Red Flags:Abbreviation: 2tfp-pe-msk-lbpDescription: LBP PE:

Vital signs reviewed. Gen Appearance: Well-appearing: Yes NO: , Well-developed: Yes NO: , Well-Nourished: Yes NO: , Acute distress: No YES:Low Back: Normal appearance: Yes NO: , Tenderness to palpation: No YES: , Muscle tightness/spasm: No YES: , ROM: Normal flexion Yes NO: , Normal extension: Yes NO: , Normal rotation: Yes NO:

MSK:

Sensation Spinal Level Body Area Right Left

L4 Medial Knee/Calf Normal Normal

L5 Lat. Leg/Dorsum of foot Normal Normal

S1 Post Leg/Lateral foot Normal Normal

Motor StrengthSpinal Level Maneuver Right Left

L4 Knee Extension 5/5 5/5

L5 Dorsiflexion of great toe/heel walking

5/5 5/5

S1 Plantar flexion/toe walking 5/5 5/5

Reflexes StrengthSpinal Level Reflex Right Left

L1-3 DTR Knee Jerk 2/4 2/4

L3-4

L5 Ankle Jerk 2/4 2/4

S1

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Maneuver/Test ( CDS http://tswf-mhs.com/stg/cds/41 )

Right Left

Straight Leg Raise

Negative Negative

Patrick-Faber

Negative Negative

Hoover Test Negative Negative

Babinski Negative Negative

Knee Abbreviation: 2tfp-hpi-msk-knee-injuryDescription:

Knee Specific HPI: ( CDS http://tswf-mhs.com/stg/cds/47 )Pt presents with Left Right Bilateral knee injury, which began __hours days weeks ago.Location:_, Quality:_, What makes it better:_, What makes it worse:_- Mechanism of Injury:- Was able to bear weight and continue activity immediately after injury: No YES: - Knee swelling/effusion: No YES, within 2 hours of injury YES, after 2 hours or more- Recurrent effusion after activity: No YES:- Pain worse with activity: No YES:- Improves with rest: No YES:- Pain going up and down stairs: No YES:- Feeling of locking: No YES:- Feeling of popping/snapping: No YES:- Feeling of giving way: No YES:

2tfp-ros-msk-knee

2tfp-pe-msk-knee

Abbreviation: 2tfp-ros-msk-kneeDescription: Knee Specific ROS: Systemic: Fever: No YES: , Chills: No YES: , Night sweats: No YES: , Unexplained weight loss: No YES: , Overweight adolescent: No YES: SKIN: Skin changes: No YES:

Abbreviation: 2tfp-pe-msk-kneeDescription:

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NO explanation is given for what a “*” means


Maybe below here we should list the abbreviations for other knee HPI options?





Knee PE:

Left Knee Right KneeGEN: - Limping gait: No YES: - Able to walk 4 weight bearing steps: Yes NO:Inspection: - Erythema: No YES: - Swelling: No YES: - Bruising: No YES: - Skin lesion: No YES: Palpation:

- Point Tenderness:- Patella: No YES:- Tibial tubercle: No YES:- Quadriceps tendon: No YES:- Anterolateral joint line: No YES:- Anteromedial joint line: No YES:- Medial joint line: No YES:- Lateral joint line: No YES:

- Iliotibial band: No YES:

- Warmth: No YES:- Effusion: No YES:- Effusion blottable: No YES:- Bony enlargement: No YES:- Palpable masses: No YES:

ROM:- Extension: Normal ABNORMAL:

- Flexion: Normal ABNORMAL:- Internal rotation of hip: Normal ABNORMAL:- External rotation of hip: Normal ABNORMAL:

Patellofemoral assessment: - Patellar tracking Normal ABNORMAL:- Crepitus: No YES:- Q-angle less than 15 degrees: No YES:- Tenderness of the patellar facets: No YES:- Patellar shrug sign/grind test: Negative POSITIVE:- Patellar apprehension test: Negative POSITIVE: - Patellar compression test: Negative POSITIVE:

ACL: - Anterior drawer test: Negative POSITIVE: - Lachman test: Negative POSITIVE: - Pivot test: Negative POSITIVE:

PCL:- Posterior drawer test: Negative POSITIVE:

MCL:- Valgus stress test: Negative POSITIVE: - Varus stress test: Negative POSITIVE Left:

Menisci:- McMurray test: Negative POSITIVE:

Strength:- Extension: Negative POSITIVE: - Flexion: Negative POSITIVE:

Neurovascular:

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- Sensation: Normal ABNORMAL:- Distal pulses: Normal ABNORMAL:

Special Tests:- Wilson’s Sign: Not Performed Findings:- Posterior Sag Sign: Not Performed Findings:

- Thessaly test: Not Performed Findings: - Noble’s Sign: Not Performed Findings:

- Ober’s test: Not Performed Findings:

Shoulder Abbreviation: 2tfp-hpi-msk-shoulderDescription:

Shoulder Specific HPI: ( CDS http://tswf-mhs.com/stg/cds/ )Pt presents with _ day week month year history of shoulder pain symptoms which include the following:

Location:_, Quality:_, What makes it better:_, What makes it worse:_- Numbness, tingling, pain radiating past elbow: No YES: - Mechanism of injury: no trauma trauma: fall fall on outstretched arm other:- Pain causes functional impact: No YES:- Pain at rest: No YES:- Pain present during activities: No YES:- Does pain affect sleeping position: No YES:- Pain present at night: No YES:- Loss of motion/stiffness: No YES:- Weakness: No YES:- Symptoms of instability/ joint laxity: No YES:- Crepitus with motion: No YES:- Past history of shoulder pain: No YES:- Previous treatment; corticosteroid injections: No YES:

2tfp-ros-msk-shoulder

2tfp-pe-msk-shoulder

Abbreviation: 2tfp-ros-msk-shoulderDescription: Shoulder Specific ROS: Systemic: Recent weight loss: No YES: Cardiovascular: Chest pain: No YES: Gastrointestinal: Abdominal pain: No YES: Red Flags: Systemic: Fever: No YES: Musculoskeletal: Shoulder mass: No YES: , Unexplained deformity: No YES: Neurological: Unexplained sensory deficit: No YES: Skin: Skin changes: No YES: Other: History of cancer: No YES: , Signs and symptoms of cancer: No YES:

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http://tswf-mhs.com/stg/cds/

Abbreviation: 2tfp-pe-msk-shoulderDescription: Shoulder PE:Left Shoulder Right Shoulder

MSK: Neck: - Normal appearance: Yes NO: - Tenderness: No YES: - Masses: No YES: Axilla: - Masses: No YES:

Chest wall: - Abnormalities: No YES:

Distal arm:- Radial pulse abnormalities: No YES:- Sensory deficits: No YES:- Motor deficits: No YES:

Shoulder:Inspection:

- Erythema: No YES:- Swelling: No YES:- Atrophy: No YES:- Winging: No YES:- Bruising: No YES:

- Deformity: No YES:

Palpation:Point Tenderness

- SC joint: No YES:- AC joint: No YES:- Biceps groove: No YES:

Sensation:- Numbness over lateral deltoid: No YES:

ROM: Passive- Extension: Normal ABNORMAL:- Flexion: Normal ABNORMAL:- Adduction: Normal ABNORMAL:- Abduction: Normal ABNORMAL:- External rotation: Normal ABNORMAL:- Internal rotation: Normal ABNORMAL:

ROM: Active- Extension: Normal ABNORMAL:- Flexion: Normal ABNORMAL:- Adduction: Normal ABNORMAL:- Abduction: Normal ABNORMAL:- External rotation: Normal ABNORMAL:- Internal rotation: Normal ABNORMAL:

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ROM Other: - “Painful arc” (pain with 70-120 degrees of active abduction): Negative: POSITIVE: - Cross body adduction test: Negative: POSITIVE:

- Apley scratch test: Negative: POSITIVE: - Crepitus: No YES:

Motor strength:- Adduction: Normal ABNORMAL:- Abduction: Normal ABNORMAL:- External rotation: Normal ABNORMAL:- Internal rotation: Normal ABNORMAL:

Special Tests: rotator cuff- Hawkins: Not Performed Findings:- Neer’s: Not Performed: Findings:- Empty can: Not Performed: Findings: - Full can: Not Performed Findings:- Lift off: Nott Performed Findings:- Drop arm: Not Performed: Findings:

Special Tests: instability- Apprehension: Not Performed Findings:- Relocation: Not Performed: Findings:- Sulcus sign: Not Performed: Findings:

Special Tests: cervical nerve root compression- Spurling: Not Performed: Findings:

Special Tests: SLAP tears/labrun/biceps- Clunk: Not Performed: Findings:- Yergason: Not Performed: Findings:

Ankle

Abbreviation: 2tfp-hpi-msk-ankleDescription: Ankle Specific HPI: ( CDS http://tswf-mhs.com/stg/cds/ )Pt presents with _ day week month year history of ankle pain symptoms which include the following: Location:_, Quality:_, Factors that correlate with onset:_, Worst pain Level:_, Least pain Level:_, What makes it better:_, What makes it worse:_Due to Injury: No YES:

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http://tswf-mhs.com/stg/cds/

- Position at time of injury: not applicable inversion eversion plantarflexion dorsiflexion rotation- Was able to bear weight for at least 4 steps immediately after injury: not applicable No YES:- Popping or snapping sound: No YES: - Swelling: No YES:- Bruising: No YES:

- History of previous ankle injuries: No YES:- Patient participates in sports: No YES:

2tfp-ros-msk-ankle

2tfp-pe-msk-ankle

Abbreviation: 2tfp-ros-msk-ankleDescription: Ankle Specific ROS: Systemic: Fever: No YES: , Chills: No YES: , Night Sweats: No YES: , Unexplained weight loss: No YES: SKIN: Skin changes: No YES:

Abbreviation: 2tfp-pe-msk-ankleDescription: Ankle PE:Left Right Ankle:Inspection: - Erythema: No YES: - Swelling: No YES: - Bruising: No YES: - Deformity: No YES:

Palpation: Point Tenderness (for Ottawa ankle rules) - Posterior edge or tip of Medial malleolus: No YES: - Posterior edge or tip of Lateral malleolus: No YES: - Base of 5th metatarsal: No YES: - Navicular: No YES: Point Tenderness (other) - Anterior talofibular ligament: No YES: - Anterior calcaneofibular ligament: No YES: - Posterior talofibular ligament: No YES: - Lateral malleolus: No YES: - Deltoid ligament: No YES: - Medial malleolus: No YES: - Anterior Tib-Fib ligament: No YES:

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ROM: - Plantar flexion: Normal ABNORMAL: - Dorsiflexion: Normal ABNORMAL: - Inversion: Normal ABNORMAL: - Eversion: Normal ABNORMAL:

Motor strength: - Plantar flexion: Normal ABNORMAL: - Dorsiflexion: Normal ABNORMAL: - Inversion: Normal ABNORMAL Left: - Eversion: Normal ABNORMAL Left:

Special Tests: - Talar tilt/Laxity: Not Performed: Findings: - Anterior drawer: Not Performed: Findings: - Thompson/Calf Squeeze: Not Performed: Findings: - Cross-leg: Not Performed: Findings: - Rotation: Not Performed: Findings:

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ProceduresAbbreviation: 2tfp-procedure-iudinsertionDescription:

IUD counseling:The patient was counseled regarding the risks, benefits and alternatives of IUD insertion and use.1. She is aware that there are other methods of contraception such as OCPs, contraceptive patches and rings and barrier methods of contraception.2. She was informed that the failure rate is about one woman for every 1000 women who use the IUD for one year. If she should become pregnant, the risk of ectopic or tubal pregnancy is about 50%. If she ever has symptoms of pregnancy, she should have a pregnancy test immediately as tubal pregnancies can be life threatening.3. Complications following insertion of an IUD are rare. There is a small possibility that the instrument used to measure the uterus or the IUD itself could perforate the wall of the uterus. This might Not be obvious immediately. If she experiences symptoms of infection such as pain, fever >100.4, chills, painful intercourse, nausea and vomiting, prolonged bleeding or foul smelling discharge, she should be seen in clinic. In the rare event that an IUD has passed through the wall of the uterus into the abdomen, it will need to be removed surgically. In extreme cases, the IUD may cause scarring which could lead to the need for a hysterectomy (surgery to remove the uterus) and the inability to have children.4. She was advised to check her string after each menstrual cycle or at least monthly and to make an appointment with her provider immediately if she is Not able to find the strings, suspects she is pregnant or experiences any of the symptoms mentioned above. All of her questions were answered and she desires to proceed with the IUD insertion.IUD insertion:The speculum was inserted and the cervix was identified. Betadine was used to clean the cervix and an os dilator and sound were used. After cleansing, sounding to a depth of [_] centimeters, and applying a tenaculum to anterior/superior cervix, an intrauterine device was inserted per manufacturer protocol. The string was cut to a 3 centimeters length and a sample of the remaining string was given to the patient for later comparison. The patient tolerated the procedure well, without any S/S of vasovagal responses, EBL less than 5 ml.

Abbreviation: 2tfp-procedure-iudremovalDescription:

IUD removal:The speculum was inserted and the cervix was identified. The IUD strings were identified and grasped with a Kelly clamp and the IUD was removed. The patient tolerated the procedure well. NO complications.

Abbreviation: 2tfp-procedure-nexplanoninsertionDescription:

Nexplanon insertionThe patient was counseled extensively regarding the risks, benefits, alternatives and possible complications of subdermal implants:

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NO explanation is given for what a “*” means



1. Contraindications include known or suspected pregnancy, current or past history of thrombosis, liver disease, undiagnosed abnormal genital bleeding, current or past history of breast cancer, allergic reaction to any components of the rods.2. She is aware of potential changes in menstrual bleeding pattern including 22% amenorrhea, 18% prolonged bleeding, 7% frequent bleeding, 34% infrequent bleeding.3. Possible adverse effects include ectopic pregnancy, thrombotic events or liver disease, depression or emotional lability, headache, weight increase.4. Subdermal implants may be used for nursing after the 4th week.Patient verbalizes understanding of procedure/treatment and agrees to proceed with Nexplanon insertion. She does Not have any further questions. [_] minutes spent teaching and counseling.

Patient identified, procedure and preferred side of placement confirmed with patient. Risks, benefits and alternatives discussed, written informed consent obtained.Left Right arm landmarks identified and insertion site and guiding site marked with retracted tip of pen. Area cleansed with betadine x3. [ ] ml of 1% lidocaine injected under the skin and along the insertion canal. In sterile fashion applicator was inspected and presence of Nexplanon device verified. Applicator used to insert Nexplanon device. Grooved tip of obturator was visible inside needle upon removal. Both myself and patient palpated the Nexplanon device in subdermal location. EBL < 1ml. Patient tolerated the procedure well. A sterile pressure dressing was applied, wound care instructions reviewed.Nexplanon Lot NO: [_]

Abbreviation: 2tfp-procedure-nexplaNonimplaNonremovalDescription:

Implanon / Nexplanon removalDiscussed procedure, risks, potential benefits and alternatives. Site identified and confirmed with patient. Marked with skin marker. Prepped in the usual sterile fashion, local anesthesia achieved with injection of [ ] ml 1% lidocaine with epinephrine into distal implant area. Performed linear incision parallel to the device. Probed wound for distal end of Implanon Nexplanon device. Device removed intact and measured to confirm. Wound edges approximated and held closed with sterile adhesive strips. Dry sterile pressure dressing placed. Standard wound care instructions provided. Instructed patient to follow-up for increased pain, redness, swelling, fever, or purulent discharge from the wound.

Abbreviation: 2tfp-procedure-colposcopyDescription:

ColposcopyThe indications, nature, and purpose of the operation/procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the operation/procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the operation/procedure.The RISKS include but are Not limited to:1. Bleeding possibly necessitating Monsels or Silver nitrate2. Infection possibly necessitating antibiotic therapy3. Allergic reaction to the solutions used in the procedure4. Possibility that the test may Not detect disease

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Alternatives: continued observation with PAP smears, but prognosis is only fair if procedure is Not performed.RECUPERATION: Generally < 1 day, bleeding, brown discharge and some cramping which may persist for 1-2 days if biopsies are taken.PROCEDURE NOTE: The speculum was inserted and the cervix was identified. The entire transformation zone and squamocolumnar junction were visualized.FINDINGS:Observation of cervix without staining: [_]Observation of cervix with acetic acid solution: [_]Observation of cervix with Lugols iodine solution: [_]Entire lesion seen? YES NOReids Index Score:- Margin - [_]- Color - [_]- Vessels - [_]- Iodine staining - [_]Pap smear repeated? YES NO ECC done? YES NO Biopsy specimens and sites: [_]Endometrial biopsy performed? YES NOVagina: Normal vaginal mucosa without lesions or evidence of genital warts.External genitalia: Normal ABNORMALPerirectal exam: Normal ABNORMALCOMPLICATIONS: There were NO complications associated with this procedure. COMPLICATIONS:

Abbreviation: 2tfp-procedure-leepDescription:

Leep:- Electrosurgical Excisional Procedure (LEEP) is being performed given her history of [_].- The patient was counseled on the risks of the LEEP procedure including bleeding, infection, damage to organs/nerves/vessels/tissues, need for additional procedure, cervical stenosis, and increased risk of preterm delivery. Informed consent was obtained and patient desires to proceed.Procedure Note:- An insulated speculum was placed in the patient's vagina.- Lugols solution was applied to cervix-lesions present as Noted and the transformation zone was visualized.- Paracervical block performed with 1% lidocaine with [_] epinephrine at 2, 4, 8, and 10 o'clock positions, [_] mL total.- The LEEP was performed with [_] passes, and ECC was obtained.- Specimens were submitted to pathology.- Roller ball cauterization was used to include a 2mm margin of the LEEP site.- Entire LEEP bed treated with Monsels solution.- Good hemostasis was achieved.- Patient tolerated the procedure well, rating post-procedure pain as documented and patient instruction provided.Patient Instructions Included:- Bleeding precautions; Pelvic rest for one month - NO tampons, douching, or sex;- Follow Up in one month for physical exam to ensure the area is healing well and to discuss pathology results.

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- Patient given contact phone number to call with any questions.

Abbreviation: 2tfp-procedure-firsttrimesterultrasoundDescription:

First trimester ultrasound The pregnancy was intrauterine.Number of Fetuses: 1 2 3 4 5Cardiac Activity: [_]CRL Measurements:CRL: [_]cm; Gestational Age: [_]CRL: [_]cm; Gestational Age: [_]CRL: [_]cm; Gestational Age: [_]IUP at [_] weeksEDC is [_] based on US LMPFollow up with provider for OB care.

Abbreviation: 2tfp-procedure-edometrialbiopsyDescription:

Endometrial biopsyThe speculum was inserted and the cervix was identified. Betadine was used to clean the cervix and an os dilator was used. After cleansing, the uterus was sounded to a depth of [_] centimeters. The endometrial biopsy pipelle was inserted into the uterus and a 360 degree endometrial sample was obtained in the usual manner. The procedure was repeated to obtain a second sample. Finally a cytobrush was used to collect any sample remaining at the os. All samples were placed in a specimen container and sent to pathology for review.

Abbreviation: 2tfp-procedure-flexsigDescription:

Flexible sigmoidoscopy The indications, nature, and purpose of the operation/procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the operation/procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the operation/procedure.

Rectal exam Normal ABNORMAL: . The endoscope was passed with ease under direct visualization to 60cm from the anus. The quality of the preparation was adequate INADEQUATE: . Retroflexion was performed NOT PERFORMED DUE TO: FINDINGS:1. The colonic mucosa appeared Normal with NO vascular abnormalities Noted ABNORMAL: 2. There were NO polyps or masses throughout the viewed area of the colon POLYPS: MASSES: POLYPS AND MASSES: .3. There were NO diverticula throughout the viewed area of the colon DIVERTICULA NOTED:4. NO internal hemorrhoids INTERNAL HEMORRHOIDS were seen on retroflexion.

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Complications: None INCLUDED:

Abbreviation: 2tfp-procedure-incisionanddrainage-abcessDescription:

Incision and drainage of abscess The indications, nature, and purpose of the operation/procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the operation/procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the operation/procedure.

Injected [_] ml of 1% lidocaine with epinephrine into abscess area. Performed linear incision over area of induration. Drained [_] ml of purulent fluid. Probed wound for loculations. Irrigated wound w/ [_] ml of [_]. Packed wound w/ iodoform gauze. Dressing placed. Instructed patient to follow-up in [_] days for wound check.

Abbreviation: 2tfp-procedure-lacerationrepairDescription:

Laceration repairDiscussed procedure, risks, potential benefits and alternatives.

Cleaned wound thoroughly with sterile water. Removed any visible foreign debris from wound. Injected [_] ml of 1% lidocaine with epinephrine into laceration and surrounding area. Closed wound with [_] deep sutures and [_] Non-absorbable sutures. Good hemostasis. Bacitracin and dressing placed. The patient tolerated the procedure well. I instructed the patient to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in [_] days.

Abbreviation: 2tfp-procedure-punchbiopsyDescription:

Punch biopsyThe procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion and infiltrated with [_] ml 1% lidocaine with epinephrine for local anesthesia. A [_]mm punch biopsy was used to remove the lesion, and the specimen was placed in placed in specimen jar and sent for analysis. Closure was performed with [_] simple interrupted sutures using [_] type of suture. Antibiotic ointment and a bandage were applied. EBL was less than 1ml. Good hemostasis. There were NO complications. Wound care and post-procedure warning signs were discussed. Patient voiced understanding. I instructed the patient to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in [_] days.

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Abbreviation: 2tfp-procedure-shavebiopsyDescription:

Shave biopsyThe procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion, and infiltrated with [_] ml 1% lidocaine with epinephrine for local anesthesia. Forceps were used to elevate the lesion and a shave biopsy was performed. The specimen was placed in a specimen jar and sent for analysis. Drysol solution was used for hemostasis. Antibiotic ointment and a bandage were applied. EBL was less than 1ml. Good hemostasis. There were NO complications. Wound care and post-procedure warning signs were discussed. Patient voiced understanding. I instructed the patient to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding.

Abbreviation: 2tfp-procedure-suturestaple-removalDescription:

Suture Staple removal S: Patient presents for suture staple removal per provider order. suture staple placed on Date: [_] location of incision: [_] reason for incision: [_] reports 0-10 / 10 pain scale at incision site.O: Examination of suture staple site free of redness, drainage or swelling. #[_] sutures/staples intact.A/P: 1. Incision site healing and skin intact. suture staple ready for removal. 2. suture staple removed using aseptic technique 3. suture staple removed by [_]

Abbreviation: 2tfp-procedure-toenailremovalDescription:

Toenail removalThe indications, nature, and purpose of the operation/procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the operation/procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the operation/procedure.

Betadine prep. Performed digital block of the [_] toe of the [_] foot using [_] ml of 1% lidocaine without epi. Elevated affected portion of nail, cut nail, removed matrix. Less than 1ml of bleeding, NO complications. Cleaned and applied bacitracin and dressed wound. Instructed the patient to follow up for fever, erythema, swelling, pain, or foul-smelling purulent discharge from the wound.

Abbreviation: 2tfp-procedure-vasectomyDescription:

Vasectomy

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The indications, nature, and purpose of the operation/procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the operation/procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the operation/procedure.

An examination of the genitals is Normal; both testes Normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.Shaft Normal, meatus Normal without discharge. NO inguinal hernia Noted. NO inguinal lymphadenopathy. Anatomic landmarks were confirmedUnder sterile conditions, a 1-2 cm wheal was made at the desired incision site with 1% Lidocaine without Epinephrine was administered to provide local skin anesthesia. The needle is then advanced through the wheal parallel and adjacent to the Left Vas and toward the external inguinal ring. After gentle aspiration, [_] ml of 1% Lidocaine without Epinephrine was injected into the external spermatic fascia.The Left Vas was maneuvered to the desired location, a 1 to 2 cm incision is made. The soft tissue is then bluntly dissected with a fine cured hemostat. The Left Vas was elevated through the incision and exposed under the midline scrotal raphe 1 cm below the base of the penis. The Vas was hemitransected and thermal cautery applied to a 1 cm length inside the lumen of the prosthetic end of the cut vas until blanching occurred. The vas was then completely transected and facial interposition achieved with a metal clip over the prosthetic end, and the testicular end left open. The area was inspected thoroughly and good hemostasis was Noted before the vas was reduced back into the scrotum. The procedure was repeated in the Right Vas. The estimated blood loss was <2 ml. Skin was dressed with sterile gauze. Tape was applied to keep the bandage on overnight, and scrotal support placed. The patient tolerated the procedure well.

Abbreviation: 2tfp-procedure-adeNOsinethalliumDescription:

Adenosine thallium Reason for test: [_]Informed consent was obtained. The indications, nature, and purpose of the procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the procedure.

The pt exercised according to the Adenosine protocol for [_] minutes. Pt’s resting heart rate of [_] bpm rose to a maximal heart rate of [_] bpm. This value represents [_] % of maximal age predicted HR. The blood pressure at rest was [_] mmHg and rose to a maximum blood pressure of [_] mmHg. The exercise test was stopped due to infusion complete.Summary:Resting ECG: [_]Functional capacity: unable to assessHR response to exercise: unable to assessBP response to exercise: unable to assessSymptoms/Chest pain: [_]Arrhythmias: [_]ST changes: [_]Mets achieved: unable to assess with adenosine test

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Overall impression: Adenosine infusion complete.Conclusion: Will wait for nuclear med studies to conclude the evaluation.( CDS Procedure codes: use both 93016 and 93018 (unless your department owns the equipment, then use procedure code 93015) )

Abbreviation: 2tfp-procedure-gxtDescription:

GXTReason for test: [_]Informed consent was obtained. The indications, nature, and purpose of the procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the procedure.

The pt exercised according to the Bruce protocol for [_] minutes. Pt’s resting heart rate of [_] bpm rose to a maximal heart rate of [_] bpm. This value represents [_] % of maximal age predicted HR. The blood pressure at rest was [_] mmHg and rose to a maximum blood pressure of [_] mmHg. The exercise test was stopped due to [_].Summary:Resting ECG: [_]Functional capacity: [_]HR response to exercise: [_]BP response to exercise: [_]Symptoms/Chest pain: [_]Arrhythmias: [_]ST changes: [_]Mets achieved: [_]Overall impression: [_]Negative or Positive Stress test.Max (=85% Max HR) or submax (<85% Max HR) stress test.Conclusion: Unremarkable GXT, low risk for CAD, NO further cardiac testing necessary.( CDS Procedure codes: use both 93016 and 93018 (unless your department owns the equipment, then use procedure code 93015) )

Abbreviation: 2tfp-procedure-circumcisionDescription:

Circumcision The indications, nature, and purpose of the operation/procedure, the expected outcome/desired results. the alternative methods of treatment, the risks involved and their relative likelihood, and the possibility of complications have been fully explained to the patient. NO guarantees have been made concerning the results of the operation/procedure. All the patient questions were answered. The patient was given the opportunity to refuse or seek alternative treatment. The patient wishes to proceed with the operation/procedure.

-Gomco Technique:The preputial opening was stretched and the synechial adhesion were broken so that the foreskin is completely retracted until the corona was visualized. A small amount of lubricant

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was applied to the glans and the bell-shaped plunger was placed over the glans covering the entire glans. The shaft skin below the corona remained relaxed and supple. The plate of the clamp was applied at the level of the corona. Once in proper alignment the clamp is tightened and a circumferential incision was made with a cold knife. The clamp was left in place for 5 minutes to allow for clotting and coagulation to occur. The clamp was then removed and antiseptic ointment was placed at the crush line. Good cosmesis and hemostasis was obtained.

-Mogen TechniqueThe dorsal tip of the foreskin is grasped with a fine hemostat for traction, and another fine hemostat is used to open the plane between the glans and the foreskin back to the corona. The first hemostat is removed and replaced on the dorsal midline with its tip about 3 mm short of the corona, and locked in place. The Mogen clamp is opened fully and was pre-operatively checked to insure that the opening is NO more than 3.0 mm. To ensure safe placement of the Mogen clamp, the glans was backed out of the way. The Mogen clamp is then slid across the foreskin from dorsal to ventral, following along the same angle as the corona with the hollow side of the clamp facing the glans. Before locking the Mogen clamp shut, the glans was manipulated to be sure it is free of the clamp jaws. Once the Mogen clamp is locked, the foreskin is excised flush with the flat surface of the clamp with a 10-blade scalpel. The clamp is left on for a few moments to insure hemostasis, then unlocked and removed. The crush line covers the glans fully with penile shaft skin. The glans is then liberated by thumb traction at the 3 and 9 o’clock positions that pulls the crush line apart. Good cosmesis and hemostasis was obtained.

Abbreviation: 2tfp-procedure-battlefieldacupunctureDescription:

A uricular Battlefield Acupuncture (BFA) : Discussed procedure, risks, potential benefits and alternatives.Examination of the ear(s) was performed and active auricular point protocol was identified and needled after being properly cleaned with Alcohol using:ASP Pionex Seirin needles were placed and removed after _ minutes without complicationNeedles were placed in order with proper precautions between each successive needle into: [_] Left Ear: Cingulate, Thalamus, Omega 2, Point Zero', Shen Men [_] Right Ear: Cingulate, Thalamus, Omega 2, Point Zero', Shen MenThe patient tolerated the procedure well and was observed for several minutes following procedure with NO lightheadedness/dizziness diaphoresis or other signs of needle shock.The patient was warned about possibility of drowsiness, lightheadedness or euphoria occurring during treatment or within 30min of treatments. Advised against driving and remaining observed during this period. Recommended avoiding heavy exertion, alcohol, undue stress for remainder of day.Aftercare for ASP Pionex needles discussed, including signs and symptoms of infection, removal if in place for more than 10 days. Educated that needles often fall out on own in 5-7 days and dislodged needles are safe around the home.The patient was asked to keep Notes of the response to the treatment, for example changes in any pain symptoms, changes in sleep patterns/depth, well-being and energy levels.

Abbreviation: 2tfp-procedure-cryotherapyDescription:

Cryotherapy

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Discussed procedure, risks, potential benefits and alternatives.

The lesion was treated with light cryotherapy using cryocautery. The nozzle of the spray gun was positioned 1.0 to 1.5 cm above the skin surface and aimed at the center of the target lesion. Liquid nitrogen is subsequently applied until an ice field encompasses the lesion and the desired margin (2-3 mm) freeze-thaw-freeze technique was performed with complete thawing of 2-3 minutes between cycles. Local care discussed. Side effects of treatment and precautions discussed. All questions answered. Patient instructed to follow up if worse or any new problems.

Abbreviation: 2tfp-procedure-cystremovalDescription:

Cyst removalThe procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion and infiltrated with 1% lidocaine with epinephrine for local anesthesia. An incision was made over the skin nodule and undermining was used to isolate and remove the cyst. The specimen was placed in specimen jar and sent for analysis. Closure was performed with [_] simple interrupted sutures using [_] type of suture. Antibiotic ointment and a bandage were applied. EBL was less than 1ml. Good hemostasis. There were NO complications. Wound care and post-procedure warning signs were discussed. Pt voiced understanding. Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in [_] days.

Abbreviation: 2tfp-procedure-excisionalbiopsyDescription:

Excisional biopsyThe procedure was explained in detail and informed consent was obtained from the patient. The area was prepped and draped in a sterile fashion and infiltrated with [_]ml of 1% lidocaine with epinephrine for local anesthesia. An elliptical excision was performed to remove the lesion/mass, and the specimen was placed in specimen jar and sent for analysis. Closure was performed with [_] simple interrupted sutures using [_] type of suture. Antibiotic ointment and a bandage were applied. EBL was less than 1ml. Good hemostasis. There were NO complications. Patient instructed to follow up for fever, erythema, swelling, pain, or purulent discharge from the wound. The patient voiced understanding. Suture removal in [_] days.

Abbreviation: 2tfp-procedure-pulmonaryfunctiontestsDescription:

Pulmonary function tests : Pre-Bronchodilator Spirometry results: FVC (% predicted Nl): [_] FEV1 (% predicted Nl): [_] FEF (25-75%) (% predicted Nl): [_] FEV1% (FEV1/FVC) expiratory vital: [_] TLC (% predicted Nl): [_] RV (% predicted Nl): [_] RV/TLC (%): [_]

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Carbon Monoxide Diffusion % (DLCO): [_]

Pre-Bronchodilator Spirometry results:FEV1 #: [_]FEV3/FVC: [_] TET: [_] ERV: [_] D/VA: [_] INTERPRETATION: [_]

Post-Bronchodilator Spirometry results: FEV1% change: [_] FEF (25-75) % change: [_] VC % change: [_] Y [_] N[_] FEV1 Change persisting post bronchodilator: [_]

Post-bronchodilator Spirometry Results:FEV1 #: [_] FVC: [_] FEV1/FVC: [_] FEV3/FVC: [_] TET: [_] INTERPRETATION: [_]

Abbreviation: 2tfp-procedure-electrocardiogramDescription:

Electrocardiogram:A 12-lead ECG with interpretation and report.

Rate: [_] NO interval change, Normal ventricular rate, Normal axis, showed P wave was

Normal, showed NO PR segment abnormalities, showed NO ST segment abnormalities, showed Normal T waves, NO Nonspecific ST-T wave changes, NO QRS abnormalities, NO Q waves, and NO poor R wave progression.

NO U wave abnormalities, NO pacemaker rhythm, NO left atrial enlargement (LAE), NO right atrial enlargement (RAE), NO left ventricular hypertrophy, NO right ventricular hypertrophy, NO combined ventricular hypertrophy, NO left bundle branch block, NO left anterior hemiblock, NO left posterior hemiblock, NO incomplete LBBB, NO right bundle branch block, NO incomplete right bundle branch block, NO bifascicular bundle branch block, NO trifascicular block, NO sinus rhythm abnormalities, NO sinus tachycardia, and NO sinus bradycardia.

NO atrial arrhythmias, NO atrial fibrillation, NO first-degree atrioventricular block, NO second degree, and NO complete heart block. NO ventricular arrhythmias and NO premature depolarization. NO preexcitation.

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STOP HERE!! STOP HERE!! STOP HERE!

CDS

Pediatric Cold

Parent education: Colds are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. There is no single treatment that produces significant improvements in symptoms of the common cold. Over-the-counter cough and cold medications for children younger than six years are ineffective and are associated with overdose and toxicity. Extra fluid intake in children is Not advised because of potential harm.

Symptomatic treatment options with potential benefit:<1 y/o: acetaminophen (fever) 1-5 y/o: honey (cough), acetaminophen (fever/pain) 6-11 y/o honey (cough), acetaminophen (fever/pain), ipratropium nasal spray (nasal

discharge), nasal irrigation (nasal congestion) 12-18 y/o honey (cough), acetaminophen (fever/pain), ipratropium nasal spray (nasal

discharge), oral or topical decongestants (nasal congestion)

Adult Cold

Symptomatic treatment options with potential benefit:ipratropium nasal spray (nasal discharge) honey (cough) oral or topical decongestants (nasal congestion) dextromethorphan (cough)

Patient was educated as follows: Colds are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. There is NO single treatment that produces significant improvements in symptoms of the common cold.

Pediatric Bronchitis

1. Referring to bronchitis as a “chest cold” increases patients’ acceptance of Not receiving antibiotics

2. NOT indicated: CXR/bronchodilators/ABX

Symptomatic treatment options with potential benefit:

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Some of these need abbreviations

-dextromethorphan-guaifenesin-honey for cough

Parent education: “Chest Colds” are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. Over-the-counter cough and cold medications for children younger than six years are ineffective and are associated with overdose and toxicity.

Adult Bronchitis

1. Referring to bronchitis as a “chest cold” increases patients’ acceptance of Not receiving antibiotics

2. NOT indicated: bronchodilators/ABX 3. Indications for CXR: pulse >100/minute, respiratory rate

>24 breaths/minute, temperature >38°C [100.4°F], or oxygen saturation <95 percent

Symptomatic treatment options with potential benefit:-dextromethorphan-guaifenesin-honey for coughPatient education: “Chest Colds” are self-limited, usually lasting up to 10 days; therefore, management is directed at symptom relief rather than treating the infection. Over-the-counter cough and cold medications for children younger than six years are ineffective and are associated with overdose and toxicity. Multiple studies show no benefit from decongestants, antihistamines, codeine, beta agonists or ABX for treatment of acute bronchitis.

Abbreviation: 2tfp-plan-peds-sinusitis-acuteDescription:

Pediatric AcuteABX indicated due to:

1. persistent illness (nasal discharge [of any quality] or daytime cough or both lasting more than 10 days without improvement)

2. a worsening course (worsening or new onset of nasal discharge, daytime cough, or fever after initial improvement) 3. severe onset (concurrent fever [temperature ≥39°C/102.2°F] and purulent nasal discharge for at least 3 consecutive days other:

Imaging: -None in uncomplicated case of sinusitis -Contrast-enhanced computed tomography scan of the paranasal sinuses ordered if

the child is suspected of having orbital or central nervous system complications other:Antibiotics (10-day course):

1st line: Amoxicillin with clavulanate 45 or 90 mg/kg per day in 2 divided doses -Ceftriaxone single 50-mg/kg given either intravenously or intramuscularly (for

children who are vomiting, unable to tolerate oral medication, or unlikely to be adherent to the initial doses of antibiotic)

-PCN Allergy Type 1: a combination of clindamycin and cefixime or linezolid -PCN Allergy NON-Type 1: Cefpodoxime 10 mg/kg per day orally divided every 12

hours (maximum daily dose 400 mg) or Cefdinir 14 mg/kg per day orally divided every 12 or 24 hours (maximum daily dose 600 mg)

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Follow up: If there is either a caregiver report of worsening (progression of initial signs/symptoms or appearance of new signs/symptoms) or failure to improve within 72 hours of initial management.

Adult: Acute SinusitisABX indicated if:

1. Persistent symptoms >10 days 2. Onset of severe symptoms 3. Signs of high fever (>39°C) and purulent nasal discharge facial pain lasting for at

least 3 consecutive days 4. Onset of worsening symptoms following a typical viral illness lasting 5 days that

was initially improvingImaging:

1. Not required in uncomplicated cases of sinusitis 2. A contrast-enhanced computed tomography scan of the paranasal sinuses is

indicated in recurrent sinusitis in spite of maximal medical therapy Antibiotics (5-10 day course):

1st line: Amoxicillin with clavulanate 500mg/125/mg TID (PCN Allergy/2nd line): doxycycline 200mg daily (PCN Allergy/2nd line): a combination of clindamycin 300mg TID plus cefpodoxime

200mg BID

Symptomatic treatment: Decongestants Intranasal steroids OTC analgesics Saline nasal irrigation

Abbreviation: 2tfp-plan-sinusitis-chronicDescription:

Adult: Acute ChronicDiagnosis: should be confirmed by symptoms and objective physical findings such as

a. Non-contrast-enhanced CT b. anterior rhinoscopy c. endoscopy

Symptomatic Treatment: -Saline nasal irrigation -Intranasal steroids

Acute Flare Treatment: -May consider up to 3-week course of ABX (Augmentin or high-

dose clarithromycin (500 mg twice daily for 7 days then 250 mg daily for 7 days)-Patients with polyps: oral steroids (less than 3 weeks)

Abbreviation: 2tfp-plan-pneumoniaDescription:

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AdultLabs: testing for specific pathogens should be ordered only when it would alter standard empiric therapy Radiology: chest radiography or lung ultrasonography recommendedDisposition: Pts can be managed as outpatient if CRB-65 score <2 CRB-65 (add some of responses below, If “YES” assign score of 1 0=NO 1=YES :New onset confusion 0=NO 1=YES :RR>29 breaths per minute 0=NO 1=YES :SBP < 90, or DBP < 60 0=NO 1=YES :Age 65 or olderABX Treatment:

1st Line: azithromycin 500mg day one and followed by 4 days of 250mg a day 2nd Line: doxycycline 100mg bid 5-7 days

Abbreviation: 2tfp-plan-peds-pneumoniaDescription:

PediatricImaging: CXR is Not recommended in children with mild uncomplicated acute lower respiratory tract infectionsABX Treatment:

1. ABX Not prescribed due to viral pathogens being responsible for great majority of clinical disease in preschool-aged children

2. Suspected typical bacterial etiology: amoxicillin 90mg/kg bid 7 days 3. Suspected atypical bacterial etiology: azithromycin 10mg/kg day one and

followed by 4 days of 5mg/kg a day 4. Alternative agents: levofloxacin and doxycycline

Follow up: within 48hrs of diagnosis

Abbreviation: 2tfp-plan-influenzaDescription:

Influenza

Antiviral Treatment: recommended for the following: 1. Pt is at higher risk for influenza complications 2. Pt has severe, complicated, or progressive illness 3. Previously healthy, symptomatic outpatient Not at high risk with confirmed or

suspected influenza on the basis of clinical judgment, if treatment can be initiated within 48 hours of illness onset

Antiviral medications: (oseltamivir, zanamivir, or peramivir) other:Supportive treatment: analgesics, antipyretics, rest, adequate (but Not excessive) hydration.Follow up: If symptoms worsen

PharyngitisDiagnosis: Centor score 0-1: NO ABX or RADT 2-3: perform RADT or throat CX (may perform if score is 1 and clinical suspicion is high), Treat with

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ABX if positive 4 or>: treat empirically with ABXCan consider throat culture in children with negative RADT

ABX Treatment: 1st Line: Penicillin PCN Allergy: Azithromycin

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Otitis MediaABX Indications: -2yrs and less with Bilateral AOM -6 mo and older with severe AOM (ie, moderate or severe otalgia or otalgia for at least 48 hours, or temperature 39°C [102.2°F] or higher) -2yrs and less without severe AOM: can offer observation with close follow up or ABX

ABX Treatment: 1st Line: Amoxicillin 80-90 mg/kg divided BID for 7 days PCN Allergy: Azithromycin

ADHD PedsTreatment: -<6 y/o Behavioral therapy first line: -Parent Training, Classroom management, peer intervetion -6-11 y/o first line is stimulant then Atomoxitine, guanfacine or catapress -Concerta, methylphenidate ER, Adderall XR, -12-18 stimulants first line, can add behavioral therapy (APA recommends both together, 2011).F/U: titrate every 2 weeks to effective dose or side effects, once stable on meds f/u every 3 months for 1 year, then can go to 6 months between appointments.

Gastroenteritis PedsTreatment: -oral rehydration first line, IV if needed -ondansetron oral dose 0.15 mg/kg (maximum dose of 8 mg) -? ProbioticsRehydration should be administered orally with an over-the-counter oral rehydration solution

Children should receive rapid oral rehydration (within three to four hours of symptom onset)

In infants who are breastfed, breastfeeding should continue

In infants who are formula-fed, diluting the formula is Not recommended, and special formulas usually are Not needed

As soon as the dehydration is corrected, a regular diet should resume

Ongoing diarrhea losses should be replaced with additional doses of an oral rehydration solution

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Tri-Service Workflow (TSWF) · Web viewThe glans is then liberated by thumb traction at the 3 and 9...

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