Transcript Chronic Disease or Consultant Templates

Chronic Disease or Consultant
Templates
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Chronic Disease or Consultant
Templates -- Subjective
• Patient ID
– Age, Sex, Referral Source, PCP
• Basic Hx of the condition
– Presentation
– Past Medications and why they were stopped
– Complications
– Current status and symptoms
– Patient’s understanding and goals
Patient ID– The Code
PATIENT ID: This «*age*» old ||PAT_SEX||
«*Accomp_By» was referred
by: ||REFSRC1_NAME_FIRST||
||REFSRC1_NAME_LAST||, ||REFSRC1_NAM
E_SUFFIX||. || IF PAT_SEX = "male" {His}
ELSE {Her} || current PCP is ||
CLINICALELEMENT<Patient PCP> ||. || IF
PAT_SEX = "male" {His} ELSE {Her} || current
complaints are noted above.
Patient ID—How it Prints
PATIENT ID: This 23 yr old male accompanied
by his brother, John, was referred by: Donald
T. Stewart, MD. His current PCP is LuAnn
Chen, MD. His current complaints are noted
above.
Data for Diabetes Presentation
• Date of Diagnosis
– ||CLINICALELEMENT<Diabetes Diagnosis Date>||
• Story of presentation
– ||CLINICALELEMENT<Presentation of Diabetes>||
– ||CLINICALELEMENT<Presentation2 of Diabetes>||
• Initial fasting glucose
– ||CLINICALELEMENT<Initial FBS Diabetes>||
• Initial random glucose
– ||CLINICALELEMENT<Initial Random Glucose>||
• Initial HgbA1c
– ||CLINICALELEMENT<Initial HgbA1c>||
Presentation: Type II Diabetes—The
Code
The patient was diagnosed with diabetes around ||
CLINICALELEMENT<Diabetes Diagnosis Date> when IF
PAT_SEX = "male" {he} ELSE {she} presented with
CLINICALELEMENT<Presentation of Diabetes>,
CLINICALELEMENT<Presentation2 of Diabetes>. IF PAT_SEX =
"male" {His} ELSE {Her} initial fasting glucose was
CLINICALELEMENT<Initial FBS Diabetes>, initial random
glucose was CLINICALELEMENT<Initial Random Glucose>, and
initial HgbA1c was CLINICALELEMENT<Initial HgbA1c>||.
Presentation: Type II Diabetes—How
it Prints
The patient was diagnosed with diabetes around
Summer 2006, when he presented with
abnormal glucose noted on routine exam, no
prior DKA, and > 20 lb weight loss. His initial
fasting glucose was 176 - 200, initial random
glucose was unknown, and initial HgbA1c was
8.9.
Past Medications – the code:
The following oral diabetes medications have been used in the past: ||IF
CLINICALELEMENT<Past DM Med 0 Name> = "" {none} ELSE {
CLINICALELEMENT<Past DM Med 0 Name> was stopped because
CLINICALELEMENT<Past DM Med 0 Reason>,} IF CLINICALELEMENT<Past
DM Med 1 Name> <> "" { CLINICALELEMENT<Past DM Med 1 Name> was
stopped because CLINICALELEMENT<Past DM Med 1 Reason>,} IF
CLINICALELEMENT<Past DM Med 2 Name> <> "" { CLINICALELEMENT<Past
DM Med 2 Name> was stopped because CLINICALELEMENT<Past DM Med
2 Reason>,} IF CLINICALELEMENT<Past DM Med 3 Name> <> "" {
CLINICALELEMENT<Past DM Med 3 Name> was stopped because
CLINICALELEMENT<Past DM Med 3 Reason>,} IF CLINICALELEMENT<Past
DM Med 4 Name> <> "" { CLINICALELEMENT<Past DM Med 4 Name> was
stopped because CLINICALELEMENT<Past DM Med 4 Reason>.} ||
Past Medications– how it prints:
• The following oral diabetes medications have been used in the
past: Amaryl was stopped because of hypoglycemia, Glucotrol
was stopped because of headache, rosiglitazone was stopped
because edema,
The following lipid lowering medications have been used in the
past: none
The following ACE inhibitor medications have been used in the
past: none
The following ARBs have been used in the past: none
Chronic Disease or Consultant
Templates -- Subjective
• Patient ID
– Age, Sex, Referral Source, PCP
• Basic Hx of the condition
– Presentation
– Past Medications and why they were stopped
– Complications
– Current status and symptoms
– Patient’s understanding and goals
Complications of Diabetes
• Neuropathy
– Pain, numbness, gastroparesis, orthostasis
• Nephropathy
– Urine Protein, Creatinine, eGFR
• Eye Complications
– Retinopathy, cataracts
• Skin Ulcers
– Location, infection present?
Neuropathy Code using Lab Data
Values
Neuropathy:
«del»|| LAB<SymetDistDysesthes> ||
«del»|| LAB<Mononeuropathy> ||
«del»|| LAB<Distal Numbness> ||
«del»|| LAB<Gastroparesis>||
«del»|| LAB<Orthostatic Sx> ||
«del»|| LAB<Diarrhea> ||
«*EditSymetDistDysesthes»
«*EditMononeuropathy»
«*EditDistalNumbness»
«*EditGastroparesis»
«*EditOrthostaticSx»
«*EditDiarrhea»
Neuropathy-what you see in the
template
«del» SymetDistDysesthes: none
«del» Mononeuropathy: none
«del» Distal Numbness: none
«del» Gastroparesis: none
«del» Orthostatic Sx: none
«*EditSymetDistDysesthes»
«*EditMononeuropathy»
«*EditDistalNumbness»
«*EditGastroparesis»
«*EditOrthostaticSx»
«del» Diarrhea: none
«*EditDiarrhea»
Quick Text to Edit a Line
Neuropathy-if you click an *Edit….
quicktext
Nephropathy
• Initial Presentation Data
– First Abnormal Microalbumin/Creatinine
– First Abnormal 24 hour urine protein
– First Creatinine over 1.6
• Most Recent Values
– 24 hour urine protein
– Spot urine protein
– Microalbumin/Creatinine
– Blood Creatinine
– Estimated GFR
– Dialysis status
– Nephrologist
Nephropathy—Initial Presentation
• First run through on how to put this together:
• Nephropathy first abnormal values:
||CLINICALELEMENT<First Abnormal Microal/Creat>|| «*Edit1stAbnMicroal/Creat»
||CLINICALELEMENT<First Abn 24 Hr Urine Protein>|| «*Edit1stAbn24HrUrineProtein»
||CLINICALELEMENT<First Creatinine over 1.6>||
«*Edit1stCreatinineOver1.6»
“Natural Language” conditional logic
|| IF CLINICALELEMENT<First Abnormal Microal/Creat> = "" {We have no
record of previous abnormal Microalbumin/Creatinine ratios.} ELSE
{PAT_FNAME's first abnormal Microalbumin/Creatinine ratio was
CLINICALELEMENT<First Abnormal Microal/Creat>.}
IF CLINICALELEMENT<First Abn 24 Hr Urine Protein> = "" {We have no
record of previous abnormal 24- hour urine protein values} ELSE {IF
PAT_SEX = "male" {His} ELSE {Her} first abnormal 24 hour urine protein
value was CLINICALELEMENT<First Abn 24 Hr Urine Protein>.}
IF CLINICALELEMENT<First Creatinine over 1.6> = "" {We have no record of
previous creatinine values over 1.6.} ELSE {The patient's first serum
creatinine value over 1.6 was CLINICALELEMENT<First Creatinine over
1.6>.} ||
“Natural Language,” the way it prints
Nephropathy:
Mickey's first abnormal
Microalbumin/Creatinine ratio was 146 on
05/17/2007. His first abnormal 24 hour urine
protein value was 2.5 grams in June, 2007. The
patient's first serum creatinine value over 1.6
was 1.8 in February 2005.
Most Recent Renal Values – the Code
Most recent recorded renal values:
«del»|| LAB<MICROALB/CREAT>[-Date] || «*EditMicroal/Creat»
«del»|| LAB<24Hr Urine Protein>[-Date] || «*Edit24HrUrineProtein»
«del»|| LAB<PROTEIN-UA>[-Date] ||
«*EditProtein-UA»
«del»|| LAB<CREATININE>[-Date] ||
«*EditCreatinine»
|| IF LAB<Race> = "Black" or LAB<Race> = "Hsp-Black" {LAB<eGFR(BLK)>[Date] «*EditeGFR(BLK)»
ELSE
{ LAB<eGFR(NBLK)>[-Date] «*EditeGFR(NBLK)» } ||
«del»|| LAB<Dialysis>[-Date] ||
«*EditDialysis»
«del»|| LAB<*Nephrologist> ||
«*Edit*Nephrologist»
Recent Renal Values – How it Looks
Current Diabetes Sx: the Code
«del»|| LAB<HypoglycemicEpisod>|| «*EditHypoglycemicEpisod»
«del»|| LAB<LowerExtrPains> ||
«*EditLowerExtrPains»
«del»|| LAB<LowerExtrNumbness>|| «*EditLowerExtrNumbness»
«del»|| LAB<Polyuria> ||
«*EditPolyuria»
«del»|| LAB<Polydipsia>] ||
«*EditPolydipsia»
«del»|| LAB<Blurred Vision> ||
«*EditBlurredVision»
«del»|| LAB<Early Satiety> ||
«*EditEarlySatiety»
«del»|| IF PAT_SEX = "male" {LAB<Erectile
Dysfunct>
«*EditErectileDysfunct»}||
Current Diabetes Sx: How it Looks
HypoglycemicEpisod: frequent moderate *EditHypoglycemicEpisod
LowerExtrPains: none
*EditLowerExtrPains
LowerExtrNumbness: none *EditLowerExtrNumbness
Polyuria: none
*EditPolyuria
Polydipsia: none
*EditPolydipsia
Blurred Vision: none
*EditBlurredVision
Early Satiety: none
*EditEarlySatiety
Erectile Dysfunct: none
*EditErectileDysfunct
*EditHypoglycemicEpisod
After Clicking
EditHypoglycemicEpisodes
Current Status—using a table to
present past values – the code
How it shows in the template
What it shows the next time
Chronic Disease or Consultant
Templates -- Subjective
• Patient ID
– Age, Sex, Referral Source, PCP
• Basic Hx of the condition
– Presentation
– Past Medications and why they were stopped
– Complications
– Current status and symptoms
– Patient’s understanding and goals
Patient understanding and plan
• Blood glucose level where hypoglycemic Sx noted
– CLINICALELEMENT<Hypoglycemic Sx Level>
• Does the patient carry ID of diabetes?
– LAB<Carries DM ID?>
• Does the patient carry glucose?
– LAB<Carries Glucose?>
• Does the patient carry glucogon?
– LAB<Carries Glucogon?>
• Does the patient have a diabetes-aware buddy?
– LAB<BuddyAwareDMCare?>
• Who is the buddy?
– CLINICALELEMENT<Buddy Aware Hypoglycemic Care>
Patient understanding - code
Hypogylcemic Plan:
The patient notices the symptoms of low glucose when his glucose level is less than
||CLINICALELEMENT<Hypoglycemic Sx Level>||. «*EditHypoglycemicSxLevel»
|| IF PAT_SEX = "male" {He} ELSE {She} IF LAB<Carries DM ID?> = "yes" {carries or
wears identification that he has diabetes} ELSE {does not carry or wear
identification that he has diabetes} IF LAB<Carries Glucose?> = "yes" {, carries
glucose} IF LAB<Carries Glucagon?> = "yes" {, carries glucagon}.
|| «*EditHypoglycemicPlan»
|| IF LAB<BuddyAwareDMCare?> = "yes" {The patient has people close to IF PAT_SEX
= "male" {him} ELSE {her} who are aware of the symptoms of hypoglycemia and
who know what to do to help, should he develop those symptoms. These people
are CLINICALELEMENT<Buddy Aware Hypoglycemic Care>} ELSE {The patient does
not have anyone close to IF PAT_SEX = "male" {him} ELSE {her} who is aware of
the symptoms of hypoglycemia and who knows what to do to help, should he
develop these symptoms. IF PAT_SEX = "male" {He} ELSE {She} was advised to
seek out several people to assume this role.} || «*EditBuddyAwareHGCare»
Patient understanding – when the
template opens