ENCOUNTER NOTES

Scores and note templates

Describe the case and the chat hands you the tool.

You don’t go looking for these. Describe the case and the chat offers the right tool under its reply.

HEART ScoreMajor adverse cardiac event risk in chest pain233 of 54 of 55 of 5

History

Slightly suspicious0Moderately suspicious+1Highly suspicious+2

ECG

Normal0Non-specific repolarization+1Significant ST deviation+2

Age

< 45045–64+1≥ 65+2

Risk factors

No known risk factors01–2 risk factors+1≥ 3, or known atherosclerotic disease+2

Troponin

≤ normal limit01–3× normal limit+1> 3× normal limit+2

MDM

54M presents with chest pain. Differential includes ACS, pulmonary embolism, aortic dissection, and musculoskeletal etiologies. HEART Score: 3, Low risk for major adverse cardiac event.

Describe a chest pain and the HEART score opens. One click puts it in your MDM. Wells, PERC, Ottawa and more work the same way.

Critical CareAdds to Procedures, exactly as written

Critical care time (minutes)***30

30992917599291 + 9929210599291 + 99292 ×2

Critical care time was exclusive of

separately billable procedurestime on other patientsteaching

Conditions

circulatory failureshockmetabolic crisisrespiratory failureCNS failure or compromiserenal failurehepatic failure

Procedures

Critical care time (minutes): 30 Critical care time was exclusive of: separately billable procedures, time on other patients, and teaching

Critical care was necessary to treat or prevent imminent or life-threatening deterioration of circulatory failure, shock, and metabolic crisis.

Critical care time was spent personally by me on history from patient or surrogate, examination, re-evaluation, ordering and reviewing labs, blood draws, ordering and reviewing imaging, treatments and interventions, evaluating response to treatment, and treatment planning with patient or surrogate.

Care was discussed with the admitting provider.

Say you did critical care and the note opens. Fill it in and Add to note writes it, as filled in, to Procedures.

Templates cover critical care, the sepsis reassessment, and procedures such as central lines, intubation, lumbar puncture, laceration repair, abscess I&D and splinting. A template is written into the note exactly as you filled it in; the MDM doesn’t reword it.

Scores and note templates

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