Brigham and Women's Hospitals

Epic Note Template

Example Note Template: Inpatient Floor

IMPORTANT: This is an example of a possible template admission note. Smartlinks are NOT universal across computer systems. This note should not be copied and used directly for patient care. We are working to make templates available through the Epic Community Library.

SPECIAL PATHOGENS UNIT ADMIT NOTE

Patient: @NAME@

MRN: @MRN@

Admission Date: @ADMITDT@

CC: @CHIEFCOMPLAINTNNOLINE@

@HPIBEGIN@: ***

@EDTRIAGEVITALS@

ED Meds: @EDMEDS@

ED Course: ***

@HPIEND@

@ROSBEGIN@

@REVIEWOFSYSTEMSCV@

@ROSEND@

@MEDSBEGIN@

@PTAMEDSIP@

@ALLERGY@

@MEDSEND@

@PHBEGIN@

@PMH@

@PSH@

Social History

Patient lives***.

@SOC@

Family History

@FAMHXP@

@PHEND@

@EXAMBEGIN@

@FLOW(6::1)@ | P @FLOW(8::1)@ | BP @FLOW(5::1)@ | RR @FLOW(9::1)@ | SpO2 @FLOW(10::1)@ | @FLOW(250026:LAST:1)@ | FiO2 @FLOW(301550::1)@ | @FLOW(14::1)@

@PHYSICALEXAM@:

@EXAMEND@

@DATABEGIN@

{labs:18171}

Labs reviewed and significant for: ***

EKG reviewed and significant for: ***

Microbiology reviewed and significant for: ***

Radiology reviewed and significant for: ***

@DATAEND@

@PHSSUMMARY@

@PHSLASTPROBAPNOTES@

#C/f COVID19

#Fever, cough

#Acute Hypoxemic Respiratory Failure

Ddx: COVID vs other viral pneumonia vs bacterial pna

*** Overall patient's respiratory status appears to be worsening given increased oxygenation requirements.

Suspicion of COVID high due to:

-Clinical syndrome (fever, fatigue, dry cough, anorexia, myalgias, dyspnea, sputum production).

-Lymphopenia

-Thrombocytopenia

-Transaminitis

-CRP

-Elevated D-dimer

-Less likely bacterial pneumonia given low procal, but will cover for community acquired pneumonia for 24-48h

Dx:

[ ] f/u SARS-COV2 PCR

- Admission studies should include: CBC, CMP, LDH, CRP, D-dimer, Ferritin, Tn, CPK, procal, EKG

- F/u viral markers (Influenza A, B, RSV, Adenovirus, human metapneumovirus PCR, rhinovirus, parainfluenza)

- ID consult for consideration of enrollment in clinical trial/s

Tx:

- Maintain O2 sat 92-96%

- Avoid aerosolized treatments, humidified O2, and NIPPV; use inhalers instead of nebs if bronchodilators needed. Can use regular NC, Venturi mask, oxymizer, or nonrebreather. If continues to decline, proceed with intubation.

- Avoid maintenance IVF or boluses where possible, favor conservative fluid management.

- Antibiotics:

- S/p *** in the ED

- Will treat for CAP: ceftriaxone 1g q24h + doxycycline 100mg bid

- Symptomatic treatment with: Tessalon pearls, Robitussin PRN, Tylenol PRN

- Strict isolation per COVID protocol

- WHO and CDC recommend glucocorticoids not be used in patients with COVID-19 pneumonia unless there are other indications (eg, exacerbation of chronic obstructive pulmonary disease)

- Update family as frequently as possible; they have been advised to stay out of the hospital given exposure risk.

-GOC discussed with patient, focusing on realistic goals for prognosis amidst COVID pandemic ***.

DVT Ppx: {IP DVT PROPHYLAXIS:22062} (Increased risk of risk of DVT with COVID).

MA PMP Database was reviewed: {YES/NO/NOT AP:21359}

@EMERCNT@

CODE STATUS: @RRCODESTATUS@.