Below are my note templates. To set these up for yourself, follow these steps:
- Open PowerChart
- Open any patient's chart
- Click on +Add PowerNote
- Select "Encounter Pathway," type "nsgy" into the search bar, scroll down to NSGY Trauma Progress Note, change Title to "NSGY Progress Note (PDI)," and hit "Ok."
- Click in the text box just above "Basic Information" and paste the note template you have copied from below.
- Open the Documentation menu and select "Save as Precompleted Note."
- Click "Save as New"
- Click cancel and discard all changes
To use a note template:
- Click +Add PowerNote
- Go to "Precompleted" and select your note template from there
Progress note template
NEURO EXAM:
A&O x 3
PERRL, EOMI, FS, TM
5 / 5
5 / 5
FC x 4
no drift
SILT
No hyperreflexia, Hoffman, clonus, or Babinski
Perianal sensation intact, sphincter tone present, voluntary anal contraction present, deep anal sensation present
PLAN:
-
Ali Alattar, MD
Neurosurgery Resident
Pager x6217
Discharge summary template
Attending:
Name/MRN:
Dates of Admission:
Diagnosis:
Procedures:
Dispo:
Pertinent Prescriptions:
Follow-up:
Labs/Rads:
Hospital course:
Neuro exam at admission:
Neuro exam at discharge:
Ali Alattar, MD
Neurosurgery resident
Pager x6217
EVD Post Procedure Note
The patient's family provided consent for the procedure. The procedure was carried out in the ICU under sterile conditions. A timeout was performed with the ICU staff identifying correct patient and sites. The skin was prepped with chlorhexidine. On the R the site of interest was covered with the fenestrated drape, Kocher's point marked, and the site anesthetized using 2% Lidocaine with epinephrine until a weal was raised. A linear incision was made down to bone. The pericranium was stripped using the blunt end of the instrument. Hemostasis was achieved with the self-retaining retractor. Kocher's point was remeasured before drilling then a burr hole was created. Residual bone particles were removed. The dura was incised in a cruciate fashion. An antibiotic-impregnated EVD was passed 6.5 cm into the brain with return of clear CSF. Opening pressure >20 cm H2O. The drain was secured at the skin with a 2-0 silk suture and incision was closed with a running 3-0 nylon suture.
Lumbar Drain Procedure Note
A lumbar drain was inserted at the bedside with full sterile prep and drape, full gown and sterile gloves were used. One attempt at L4/5. Catheter was passed to 3 dots at the skin. Brisk CSF outflow was confirmed at each step of the procedure and at the end in the Buretrol. A releasing loop was secured at the skin with 3-0 nylon sutures and staples. A buddy stitch was placed.
Consult Note
Attending:
CC:
HPI:
PMH:
PSH:
Meds: no aspirin, Plavix, Coumadin, Eliquis, Xarelto, Pradaxa
Allergy: NKA
Social: Lives: , Works: , Baseline: , Family support: , Tobacco: denies, EtOH: denies, Illicit drugs: denies
NEURO EXAM:
A&O x 3
PERRL, EOMI, FS, TM
5 | 5
5 | 5
FC x 4
no drift
SILT
No hyperreflexia, Hoffman, clonus, or Babinski
Perianal sensation intact, sphincter tone present, voluntary anal contraction present, deep anal sensation present
IMAGES: Server ***:
Plan:
-
Staffed with Chief Dr. *** and Attending Dr. ***
Ali Alattar, MD
Neurosurgery Resident
Pager x6217
Shunt Tap Procedure Note
The patient/patient's family provided consent for the procedure. The procedure was performed in the ED vs ICU under sterile conditions. The shunt catheter and valve were prepped with Chlorhexidine and draped in the usual fashion then re-prepped with iodine. A butterfly needle was used to access the shunt valve reservoir vs Rickam. Brisk flow of CSF was noted. Opening pressure was ***. *** ccs of clear CSF were drained. Closing pressure was ***. Patient tolerated the procedure well and no complications were noted.
