I designed a GUI template to document ENT discharge instructions, and have included a screenshot. Works really well, I'm happy with it. In the past, I have found many patients for ENT exams are in a hurry or I know them pretty well, so sticking a format discharge instructions sheet in their hands every time is a annoying. On the other hand, I'm a stickler for writing down a very brief version of what I told them under plan, and title it with "Discussed With Patient". This has saved my butt many more times than once. I'm thinking of making these ENT instuctions into a prescription-blank sized tear off hand-out, so will be easier to use and less obtrusive. I used the Synapse Directive "letter" so prints one instruction per line and formats nicely Only the "HOME INSTRUCTIONS" header prints if you select "Save" The ADDITIONAL INSTRUCTIONS header is optional text.
Sure, here's one I just did: HOME INSTRUCTIONS: Aleve Loratadine Increased intake of Vits D and C Go to ER if sustained fever >103, Shortness of Breath, blood in phlegm, chest pain, shaking chills, or any unusual symptoms. Soothing OTC lozenges, such as Vick's Chloraseptic or Cepastat Followup with your doctor in 5-7 days ADDITIONAL INSTRUCTIONS: High Volume Low-Pressure saline irrigation twice a day chronically may be helpful for your chronic sinus condition
Some people do listen to more theory about OM, mono, recurrent sinusitis, and so forth. I often refer them to WebMD, Medscape and so forth. I'm not quite sure how to work that into my URI instructions, but I will try to add more stuff over time. Many people just come to urgent care to get ABX so we try to educate them about Vit D, lifestyles, healthier living, etc.. So probably putting in links to reliable webpages they could look up would be a good start.
Ok, just that "Aleve Loratadine Increased intake of Vits D and C" doesn't mean a lot to me ...it's not very explicit.
Yes, I see what you mean. It only makes sense to myself and the patient when recorded telegraphically that way. I should record that I discussed the use of Loratadine as a nonsedating antihistamine, and suggested it's likely to be tolerated better than pseudoephedrine, but possibly less effective. Hmm.. have to think about a little more explanatory script here..
i think this i slike having order sets. eg if a pt comes in with cp usual order like ekg enzymes etc. and f/u with md in one week. just use the template add a check box in front and your off. would be nice if there was a book or site with premade instructions like webmd etc we could cut from and decrease font size to fit on one page.
The detailed mode allows you to memorize a set of instructions/meds etc for a particular ICD9, and to recall it.
