Clinical Decision Making SmartPhrases.

[RustedFox]

Not long ago, someone mentioned that we should create a "databank" of CDM phrases regarding MDM/etc that we felt were rather medicolegally useful for community sharing/use. This thread can be that place to contribute.

Here's my first offering, for "headache" patients that you are sure you don't want to CT/LP:

"Care was taken during ROS to review and identify any signs/symptoms to suggest the possibility of SAH - but the patient denies any sudd-onset or "thunderclap" headache, denies this being the "worst headache of their life", and denies any family history of aneurysmal disease. Furthermore, the neck exam is benign and reassuring in its entirety. Decision made together with patient after risk/benefit discussion to NOT proceed with CT/LP to further evaluate for SAH, given the low clinical suspicion for this patient's presentation."

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[bravotwozero]

Stupid question - how do you enter the shortcut for the smart phrase in epic?


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[deleted109597]

Stupid question - how do you enter the shortcut for the smart phrase in epic?


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Smartphrase manager.
And you can do anything. It can even be pictures if you want.

 

[southerndoc]

Careful posting your smart phrases on the internet for the attorneys to find. 🙂

 

[res1cue]

Not long ago, someone mentioned that we should create a "databank" of CDM phrases regarding MDM/etc that we felt were rather medicolegally useful for community sharing/use. This thread can be that place to contribute.

Here's my first offering, for "headache" patients that you are sure you don't want to CT/LP:

"Care was taken during ROS to review and identify any signs/symptoms to suggest the possibility of SAH - but the patient denies any sudd-onset or "thunderclap" headache, denies this being the "worst headache of their life", and denies any family history of aneurysmal disease. Furthermore, the neck exam is benign and reassuring in its entirety. Decision made together with patient after risk/benefit discussion to NOT proceed with CT/LP to further evaluate for SAH, given the low clinical suspicion for this patient's presentation."

Recently added a line about CO poisoning on my smart phrase. Also helps remind me to ask about it since it is never on my differential otherwise