March 7, 2008

New Sepsis Evaluation MedicalTemplate

The sepsis evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected sepsis, SIRS, or septic shock.

The sepsis evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity, including critical care.

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Sepsis Evaluation Date Start time Stop time Patient Name Chief complaint/Reason for consult Patient DOB Referring MD MRN Allergies ‰ Allergy List reviewed ‰ No drug allergies ‰ No food allergies Medications History of Present Illness ‰Patient is Nonverbal. History obtained from ‰ Family ‰ Medical records ‰Medication list reviewed ‰Medications reconciled with Nursing Home or Hospital discharge Information œ46 ‰Heart rate t 90 ‰Temp d36 C or t 38 C ‰Resp rate t 20 OR PCO2 d 32 on ABG ‰WBC d4000 ORt 12000 OR t 10% Bands ‰Positive blood culture = Sepsis PLUS = Systemic Inflammatory Response Syndrome PLUS ‰SBP < 90; MAP d 70 mmHg OR drop of t 40 mmHg = Severe Sepsis PLUS ‰Systolic BP d 90,or MAP d 70 = Septic Shock Social History ‰Never Smoker ‰Tobacco ____ # Packs X ____ # Yrs ‰ Quit Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ ‰ WNL ‰Alcohol use Drinks per ‰day ‰week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day 1 “drink” is equal to 12 oz. beer,1.5 oz. 80-proof liquor, or 5 oz. glass of wine Constitutional ‰Fatigue ‰malaise ‰fever/chills ‰Appetite changes Eyes ‰Vision changes ‰New pain ‰Scotomas ENT/mouth ‰Nose bleeds ‰Dental caries ‰Dental abscesses ‰Jaw pain Resp ‰Dyspnea ‰Cough ‰Phlegm ‰Hemoptysis ‰Wheeze CV ‰Chest pain ‰Diaphoresis ‰Ankle edema ‰PND ‰Syncope GI ‰Nausea ‰Weight changes ‰Constipation ‰Diarrhea ‰Abdominal pain GU ‰Change in urinary habits ‰Hematuria ‰Dysuria Musc ‰Myalgias ‰Recent trauma ‰Bony fractures ‰Arthralgias ‰Joint swelling Skin/breasts ‰Rashes ‰Masses or skin lesions ‰Increased sensitivity to sun Neuro ‰Seizures ‰Episodic or chronic muscle weakness ‰Headaches Endo ‰Hair loss ‰Polydipsia ‰Tremors ‰Neck pain Heme/lymph ‰Bleeding gums ‰Unusual bruising ‰Lymph nodes, tender or swollen Allergy/Immun ‰Sinus probs ‰Recurrent infections Psych ‰Mood changes ‰Agitation ‰Psychosis ‰Delirium ‰Dementia ‰Recreational drug use ‰Inhalational ‰Injectable ‰Ingestible ‰Drug dependence ‰Narcotics ‰Benzodiazepines Family Medical History ‰ Asthma ‰ Congestive Heart Failure ‰ COPD ‰ Coronary Artery Disease ‰Premature Onset ‰ Malignancy ‰ Pancreatitis ‰ Peripheral Artery Disease ‰ Renal Dysfunction ‰ Thrombotic disorder ‰ Thyroid Disease Occupational and Exposure History ‰Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter ‰Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals ‰Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic ‰Chemicals or fires ‰Trauma Vaccines ‰Flu ‰Pneumo ‰BCG ‰Tetanus ‰Pertussis ‰Varicella ‰CABG ‰Splenectomy ‰Pituitary resection ‰Organ transplant ‰Other Surgeries Past Medical and Surgical History ‰Asthma ‰Adrenal dysfunction ‰Arthritis ‰Cerebral Artery Disease ‰CHF ‰COPD ‰Coronary Artery Disease ‰Cystic Fibrosis ‰Diabetes ‰1 ‰2 ‰GERD ‰Gout ‰Hepatic dysfunction ‰HIV/AIDS ©MB and RR 2006-2008 ‰Hypertension ‰Inflammatory Bowel Disease ‰Malignancy ‰Myocardial Infarction ‰Neuromuscular weakness ‰Pancreatitis ‰Peripheral Artery Disease ‰Renal dysfunction ‰Thrombotic disease ‰Thyroid disease, hyper ‰Thyroid disease, hypo ‰Seizure disorder ‰Sleep Apnea ‰Chemotherapy ‰Colonoscopy ‰ECHO/Stress test ‰Immunosuppressive therapy ‰Mammogram ‰Organ failure ‰PFTs ‰Pap Smear ‰Prior intubations ‰Radiation exposure ‰Sleep study ‰Steroid use, chronic ‰Strokes Revised7Aug08 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Sepsis Evaluation IV Medications & Labs Patient Name Exam Ventilator Mode Rate Patient DOB MRN ‰ Pressors ‰ Diuretics ‰ Heparin ‰ Thrombolytic ‰ Insulin ‰ Sedation ‰ Steroids ‰ Antibiotics ‰ TPN ‰ Narcotics ‰ Antiarrhythmics ‰ Crystalloids \____/ / \ ____ / ____ / ____ / \ \ \ ‰AC ‰SIMV + Pressure Support ‰Pressure Control ‰Pressure Support ‰Airway Pressure Release PEEP PS FiO2 PO2/FiO2 Plateau Pressure Tidal Vol NonInvasive Ventilator (CPAP, BiPAP) Settings General Eyes ENT Neck Resp ‰Clear to auscultation ‰ Clear to percussion CV ‰Auscultation ‰ Palpation ‰ Edema ‰Carotids ‰Alert Vitals T P ‰Conjunctivae ‰Pupils ‰Discs ‰Nasal mucosa ‰Dentition ‰Oropharynx ‰Normal to palpation ‰Thyroid ‰No JVD R BP Sats % Mallampati ‰I ‰II ‰III ‰IV GI ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux ‰No abdominal/flank ecchymoses Lymph ‰No lymphadenopathy ‰Enlarged lymph nodes palpable ‰Neck ‰Axilla ‰Groin ‰Other Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength Extrem ‰No clubbing ‰No cyanosis Skin ‰Inspection ‰Palpation ‰Effort ‰Normal to palpation ‰ Aorta ‰Femoral pulses ‰ Pedal pulses Neuro ‰Oriented œ58(Pts with Community Acquired Bacterial Pneumonia) Psych ‰Affect ‰Orientation ‰Insight ‰Memory Additional Findings ‰CN ‰DTR ‰Sensation Glasgow Coma Score E ____ V ____ M ____ Recommendations Impression APACHE II Score ____ APACHE IV Score _____ ‰Aggressive pulmonary toilet ‰DVT prophylaxis ‰Stress ulcer prophylaxis ‰Stop sedation daily assess neuro status ‰Head of bed >30 Degrees at all times ‰Insulin infusion ‰Pneumonia vaccine prior to discharge ‰Influenza vaccine prior to discharge ‰Central line placement ‰Central line change/removal Culture tip ‰Physical therapy ‰Enteral/Parenteral feeds ‰CVP monitor placement ‰Central or Mixed Venous O2 ‰12-lead EKG ‰Echocardiogram ‰CBC ‰CMP ‰PT, PTT, INR ‰Lactate ‰Random cortisol level ‰Toxicology Screen ‰Blood Alcohol level ‰Blood cultures x 2 ‰Broad spectrum antibiotics ‰Pseudomonas suspected Goal t 70% Goal CVP 8-12 ‰Shock requiring ‰Large volumes of Fluid ‰Pressors ‰Likely source of infection or ischemia present, describe ‰Acute renal failure ‰with chronic failure ‰with ESRD ‰Acute hepatic failure ‰with chronic failure ‰Acute heart failure ‰Right ‰Left ‰with chronic failure ‰Acute respiratory distress syndrome ‰Acute respiratory failure ‰with chronic failure ‰Disseminated Intravascular Coagulation ‰Adrenal Crisis OR ‰Relative Adrenal Insufficiency ‰Multiple Organ Dysfunction Syndrome Signature cc ‰ Patient has completed advanced health care directivesœ47 HCPOA is Code Status ‰ Patient is a FULL CODE ‰ DO NOT ATTEMPT RESUSCITATION Data Reviewed: Care Coordinated with: ‰ER Notes ‰Chart ‰Nursing Notes/Vitals log ‰Labs ‰Radiology data ‰ECHO ‰ECG ‰Stress Test ‰PFT ‰HCPOA ‰ PCP ‰Case Mgmt or SW ‰Pharmacy ‰Nursing Revised7Aug08 œIndicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures ©MB and RR 2006-2008

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