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Typing Templates - exported from EMR and updated every 2nd Monday of the Month.
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| Code | Description | Content |
| 8 | Positive | Positive |
| 9 | Non-Reactive | Non-reactive |
| 35 | Reactive | Reactive |
| 1D | 1 day | 1 day |
| 1W | 1 week | 1 week |
| 1Y | 1 year | 1 year |
| 24HRBPTT | Pt for 24 hour BP monitor | Pt for 24 hour BP monitor Initial BP«» Diary commenced«» Unit due back«» |
| 2D | 2 days | 2 days |
| 2MMB | 2mm biopsy - dressing | 2mm biopsy - dressing applied |
| 2W | 2 weeks | 2 weeks |
| 2Y | 2 years | 2 years |
| 3D | 3 days | 3 days |
| 3MMB | 3mm biopsy - 1 x suture, | 3mm biopsy - 1 x suture, dressing applied |
| 3W | 3 weeks | 3 weeks |
| 4D | 4 days | 4 days |
| 4W | 4 weeks | 4 weeks |
| 5D | 5 days | 5 days |
| 5W | 5 weeks | 5 weeks |
| A | (Belongings drop | (Belongings drop off) |
| AAT | Template - Assess and treat (AccelEMR) | Assess and treat (See History). |
| ABCD | Template - ABCD2 Stroke Risk Calculator (AccelEMR) | ABCD2 - Stroke Risk Stratification Calculator (for patients with TIA) - enter the risk factors-->determine score-->use interpretation table to consider actions Date: «Letter.Patient.DateLastSeen» Age«» >60 years old1 Blood Pressure«» Systolic >140mm Hg and/or Diastolic > 90 mm Hg1 Clinical Features«» Unilateral weakness «» Speech disturbance without weakness «» Other2 1 0 Duration of Symptoms«» >60 minutes «» 10-59 minutes «» <10 minutes2 1 0 Diabetes«» Diabetes Mellitus1 TOTAL SCORE«» Interpretation Score2-Day Risk of StrokeRiskTarget Referral Time 0-31%Low Risk48-72 hours 4-54.1%Higher Risk24-48 hours 6-78.1%Consider AdmissionImmediate Johnston SC et al. Lancet. 2007 Jan 27; 369:283-92. |
| ABCDE | The ABCDEs of melanoma were | The ABCDEs of melanoma were discussed. Changing lesions should be brought to medical attention. Sunsafe measures were discussed (avoidance, physical protection, and SPF > 60). |
| ABDOEX | abdomen not distended, soft, | abdomen not distended, soft, non tender, no organomegaly, bowel sounds present |
| ABDOX | Abdominal examination | Abdomen not distended, soft, non-tender, no organomegaly, BS++. |
| ABFIT | Abnormal FIT screening test | Abnormal FIT screening test info given to patient (abfit\) https://youtu.be/wfZsKxwbX_Y An abnormal FIT result means that blood was found in the stool sample that you submitted. Abnormal FIT results are common and do NOT mean that you have cancer. On average, fifteen per cent of people screened with FIT will have an abnormal result and will require additional testing. This does not mean that a cancer was found – over 96 per cent of people with an abnormal FIT result will be found to not have cancer. Some of these patients may have polyps, which are small growths that can develop in the colon or rectum, often with no symptoms in early stages of growth. Most polyps will never turn into cancer, and for those that do, it will take many years for this transition, which is why people between the ages of 50 to 74 years should be screened regularly. For more information on what it means to have an abnormal FIT result, watch this video. http://www.bccancer.bc.ca/screening/colon/results |
| ABL | abdominal | abdominal |
| ABP | abdominal pain | abdominal pain |
| ABTT | antibiotics | antibiotics |
| ACAT | Access Central - Addiction Treatment Hx | Previously received SU tx: «Y/N» Tx hx relevant to current goals/health: «» Referral support needed: «» |
| ACC | Attempted Client Contact | |
| ACCR | Access Central MD Case Review | |
| ACCRTEXT | Access Central MD Case Review | ID: «» Housing: «» Community Supports (active or previous): «» Detox booking dates in the last 12 mo (show/no show): «» Reason patient flagged for MD review: «» Patient's stated goal for detox: «» Factors affecting frequent bookings: «» Impression: «» Recommendations to implement now: «» Flagged for Complex Case Rounds: «Yes/No» Other recommendations/considerations for Complex Case Rounds review: «» |
| ACD | Access Central - Disposition | Goals of care: «» Tx setting: «» Priority: «» Interim/ongoing/discharge plan: «» Referrals needed/completed: «» |
| ACDP | Acute Care Discharge Planning (calls ACDPTEXT) | |
| ACDPTEXT | Acute Care Discharge Planning (TEXT ONLY) | Client to be discharged from hospital (confirmed: y/n) «» - Estimated date of discharge [DD-MMM-YY] «» Client discharged to: (home/other) «» Verbal handover with staff nurse or following case conference: «» Reviewed client status with hospital staff: Physical health status (baseline or permanent change) [if change, add collateral] «» Cognitive status (baseline or change) [if change, add collateral] «» Mental health status (baseline or change) [if change, add collateral] «» Functional status (baseline or change) [if change, add collateral re mobility and ADLs/iADLs] «» Medications Review any medication changes. Confirm community pharmacy and how client is to receive medications on discharge. «» Home supports Confirm date services to start/resume «» Convalescent OR referred to Home Health for long term case management? «» Create and/or update PAGs as appropriate «» Post discharge care needs [please add items that are new, remove as needed]: Wound Care (care plan received from inpatient team: y/n) «» Chronic disease management (y/n) «» Medication management (y/n) «» New Acute Illness instructions (y/n) «» Post Surgical care plan (y/n) «» Mental Health follow up (y/n) «» Psychosocial need follow up (y/n) «» Frequency and duration of follow up visits «» Community team action items: Care Plan Updated in EMR within 48 hours of discharge, including new/changed outreach needs «» Task MRP/Relevant care team members of changes «» Complete medication reconciliation within 48 hours of discharge Update EMR scripts module «» Follow-up appointments booked with Care Coordinator / Care Team and MRP «» Pending Referrals/ booked follow ups (OT, PT, specialist) «» Notify front desk/ referrals desk «» Coordinate CLW to support with appointments as needed «» |
| ACHR | Access Central - Harm Reduction Review | OD hx: «» HR (Y/N): Uses alone: «» Has naloxone: «» Life Guard App: «» OD prevention site: «» Drug checking: «» HR teaching provided: «» |
| ACLH | Access Central Referral to Lighthouse | |
| ACMDC | Access Central – MD Consult (calls ACMDCTEXT) | |
| ACMDCL | Access Central – MD-to-MD Consult Line (calls ACMDCLTEXT) | |
| ACMDCLTEXT | Access Central – MD-to-MD Consult Line (TEXT ONLY) | Referring Physician/Team/Site: «» Reason for call/referral: «» PATIENT ID: HPI: «» Abbreviated SU Hx: «» PMHx: «» Current Meds (incl. PRNs): «Enter in Usual Scripts» Housing status: «» PLAN: «» Bed requested? Yes/No Triage Priority: Urgent/High/Routine (or N/A) Rationale: «» Site selected: R2R/VDC/VCH WDM (or N/A) Planned admission date/time: «» (or N/A) Goal of admission (if bed requested): «» Transportation: «» After care plan: «» Patient information given to ARWs for booking: Yes/No For R2R: Confirm patient aware that unit 3 smoke breaks per day, limited visiting hours, limited ability to leave the unit without accompaniment. For R2R: Handover note on Cerner |
| ACMDCTEXT | Access Central – MD Consult (TEXT ONLY) | Abbreviated Consult History of Present Illness: «» Substance Use History: 1. Nicotine «» 2. Alcohol «» 3. Opioids «» 4. Stimulants «» 5. Benzodiazepines «» 6. Cannabis «» 7. Other «» Harm Reduction Review: Access to clean supplies «» Use at supervised consumption site «» Safe use practices reviewed «» Overdose prevention strategies reviewed «» THN offered «» PharmaNet Review: Last dose of OAT «» Missed doses of OAT «» PharmaNet reviewed «» Confirmed with pharmacy «» Addiction Treatment History: Psychosocial interventions «» Medications «» WD management «» Social History: Source of income «» Housed «» Social supports «» Community Addiction Provider «» GP «Add to Care Team» Community pharmacy «Add to Care Team» Past Medical History «» Past Psychiatric History «» Family History «» Medication List «Add to Usual Scripts» Allergies «Add to Adverse» Physical Exam «» Investigations: Lab Results «» Diagnostics «» Goal of Admission «» Impression/Plan: 1. OUD/StUD/AUD/NUD – mild/moderate/severe, active/in remission 2. OUD/StUD/AUD/NUD – mild/moderate/severe, active/in remission 3. OUD/StUD/AUD/NUD – mild/moderate/severe, active/in remission Bed requested? Yes/No Triage Priority: Urgent/High/Routine (or N/A) Rationale «» Site selected: R2R/VDC/VCH WDM (or N/A) Planned admission date/time: (or N/A) Goal of admission (if bed requested) «» After care plan «» Patient information given to ARWs for booking: Yes/No For R2R: ARW confirmed patient aware that unit 3 smoke breaks per day, limited visiting hours, limited ability to leave the unit without accompaniment. Disposition: Bed booked «» Housing «» Primary care «» Pharmacy «» Transportation «» |
| ACMDPR | Access Central – MD Priority Review (calls ACMDPRTEXT) | |
| ACMDPRTEXT | Access Central – MD Priority Review (TEXT ONLY) | Shared care nursing see note Booking today «» Missed intake Date «» Current booking date/site «» VCH WDM/VDC/R2R Current priority Routine/high Reason review «» Goal for admission «» A/P Reassessed priority: routine/high/urgent Rationale «» No change bed booked for «» Agree with nursing assessment bed booked for «» New booking date/site «» Transportation «» For R2R: ARW confirmed patient aware that unit 3 smoke breaks per day, limited visiting hours, limited ability to leave the unit without accompaniment. For R2R: Handover consult on Cerner |
| ACMH | Access Central - Medical Hx | Current medical conditions (stable/unstable): «» Hx recent hospitalizations: «» Medrec notes: «» Pregnancy: «» |
| ACP | Synopsis Tab - Advance Care Planning Record (AccelEMR) | Advance Care Planning Record - Guidelines for Use: S.P.E.A.K to adult about Advance Care Planning (see below) 1. To be used by all health care team members (e.g. doctors, nurses, social workers, etc) 2. Record conversations about patient’s medical condition, goals, values, CPR and treatment options, DNR/CPR status, comfort care, withholding/withdrawing support, etc. 3. Indicate if conversation was with patient (p), family (f), or substitute decision maker(s) 4. Document action taken (e.g. Physician notified, or Advance Care Plan introduced) 5. Power of Attorney - <>; Relation - <> 6. Substitute Decision Maker - <>; Relation - <> 7. Living Will Document - <> Date (dd/mm/yy)Discussionp/f/sActionInitials/Title «Letter.Patient.DateLastSeen»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» (digitized by AccelEMR Solutions) CORE ELEMENTS: ACP conversations are ongoing and may include any combination of the five [5] Core Elements. 1. S.P.E.A.K. to adult about Advance Care Planning Determine if the adult has: Chosen a Substitute Decision Maker (Representative appointed or TSDM) Thought about Preferences for treatment options. Any previously Expressed wishes (e.g. Advance Care Plan, Living Will) Written an Advance Directive or appointed or a Representative Then assess the adult and/or SDM's: Level of Knowledge regarding diagnosis, treatment options, risks and benefits. 2. Learn about & understand the adult & what is important to them. Involve Substitute Decision Maker(s). Possible questions to ask: What does it mean to live well? What gives your life meaning? What does quality of life mean to you? Tell me your thoughts about quantity of life. What fears/concerns do you have? How has your changing health status impacted you and your family? What is acceptable risk? Who or what gives you support in times of difficulty? 3. Clarify understanding & provide medical information about the disease progression, prognosis & treatment options. What is the medical assessment? Diagnosis and implications now and in the future. Expected prognosis: Months to years? Weeks to months? Days to weeks? Hours to days? How might this disease progress (include discussion regarding resuscitation (CPR) and other life prolonging treatments (dialysis, tube feeds, ventilation support, etc.) What are the expected benefits and burdens of treatment? 4. Ensure interdisciplinary involvement and utilize available resources Ensure process is interdisciplinary. Utilize available resources and expertise including MD, NP, Social work, Palliative Care; Community resources (Alzheimer's, Parkinson's or Hospice Society) If treatment is not available in current location, does the adult wish to be transferred from their current location? Options may include acute care, hospice residences, residential care, and home. 5. Define goals of care, document & create plan. Discuss specifics of plan to ensure understanding of possible complications and how to manage them. If goal may not be attainable, what are the alternatives? |
| ACP2 | Advance Care Planning Record | Advance Care Planning Record 1. To be used by all health care team members (e.g. doctors, nurses, social workers, etc) 2. Record conversations about patient’s medical condition, goals, values, CPR and treatment options, DNR/CPR status, comfort care, withholding/withdrawing support, etc. (see guiding questions below) 3. Indicate if conversation was with patient (p), family (f), or substitute decision maker(s) 4. Document action taken (e.g. Physician notified, or Advance Care Plan introduced) 5. Review of Advance Care Planning Documents (Advance Directive, Section 7, Section 9, Basic Advance Care Plan/living will, Power of Attorney, Last will and Testament) Power of Attorney - <>; Relation - <> Substitute Decision Maker - <>; Relation - <> Contact Information <> A temporary substitute decision maker may be needed to make necessary decisions on behalf of the patient if the patient is not capable to do so themselves. They make decisions based on previously expressed wishes and based on the patient’s best interests. The order of substitute decision makers is as follows unless a Legal Representation Agreement naming a decision maker is completed: 1) Spouse (married, common law, same sex) no matter how long the relationship 2) Child over 19 years old (birth order does not matter) 3) Parent (either parent including adoptive parents) 4) Sibling (birth order does not matter) 5) Grandparent 6) Grandchild (birth order does not matter) 7) Anyone else related to you by birth or adoption 8) A close friend Date (dd/mm/yy)Discussionp/f/sActionInitials/Title «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» «»«»«»«»«» Guiding questions: 1) SETUP: I’m hoping we can talk about where things are with you illness and where they might be going- is this okay? 2) ASSESS: What is your understanding now of where you are with your illness? How much information about what is likely to be ahead with you illness would you like from me? 3) SHARE: Prognosis: eg. I’m worried that the time may be short. 4) EXPLORE: What are your biggest fears and worries about the future with your health? What gives you strength as you think about the future with your illness? What abilities are so critical in your life that you can’t imagine living without them? If you become sicker, how much are you willing to go through for the possibility of gaining more time? Eg. Would you accept or refuse life support and life-prolonging medical interventions for certain conditions such as 1) Ventilator to help you breathe 2) Tube feeding 3) Kidney Dialysis 4) Cardiopulmonary Resuscitation if your heart were to stop beating 5) CLOSE: It sounds like «» is very important to you. Given your goals and priorities and what we know about your illness at this stage, I would recommend….. We are in this together. |
| ACPH | Access Central - Psych Hx | Current mental health concerns (stable/unstable): «» |
| ACSH | Access Central - Social Hx | Current supports/specify clinic/location: «» Pharmacy name/location: «» Medication coverage: «» Income source: «» |
| ACSI | Access Central Services - Intake Assessment | |
| ACSS | Access Central - Safety Screen | Additional risks to safety: «» Mobility: «» Specialized care/equipment: «» Aggression waiver: «» |
| ACSTART | Access Central Referral to START | |
| ACSU | Access Central - Substance Use History | Goals:«» Hx wd/ complicated wd/wd hospitalizations: «» Longest period of stability: «» OAT hx: «» |
| AD | Adnormal | Adnormal |
| ADDVIS1 | Addiction First Visit | Addiction Assessment - First Visit Subjective: Referred from «» Primary Substance(s) of Choice: «» Primary Route: «» Date Last Used: «» #Days of Use in Last 30 Days:«» Age at First Use: «» Current Pattern: «» Current Situation: «» Medical History: Primary care provider «Letter.Patient.DoctorUsual.FullName» Other care providers «» Medical Conditions/Co-Morbidities «enter changes in Problems» «Letter.Patient.ProblemListOther.DiagnosisActive» Current Medications «enter changes in Usual Medications» «Letter.Patient.UsualMedicationNameOnly» Allergies «enter changes in Adverse Reactions» «Letter.Patient.ProblemListOther.AdverseActive» Appetite: «» Sleep: «» Family history «» Mental Health History: Mental health diagnosis «» Current or past treatment «» Counseling «» Hospital admission «» Social History: Housing: «» Work/School: «» Income: «» Legal: «» Relationship: «» Children «» Ages «» Current Life Stressors: «» subs«to record substance use/treatment history replace this with backslash \» Overdose in the last 6 months «» in the last 30 days «» Perceived control over substance use : Y/N «» Triggers «» Protective factors/strengths/method of coping: «» Risk behaviors: needle sharing «» crime «» sex work «» driving «» unsafe sex «» others «» Objective: Vital Signs: Ht «», Wt «», BP «», PR «», Temp «», Mental Status «» Track marks: None «» Arms «» Legs «» Neck «» Abdomen «» Signs of recent opioid use: None «» Constricted pupils «» Drowsiness «» Slurred speech «» Unsteady gait «» Signs/symptoms of Withdrawal: None «» Arthralgia/myalgia «» Dilated pupils «» Diaphoresis «» Diarrhea «» Fever «» Goose flesh «» Lacrimation «» Rhinorrhea «»General - «» swi«to record withdrawal or intoxication signs replace this with backslash \» Assessment: Substance Use Disorder to: «» Stage of Change: «» Plan: «» Pharmanet Check «» Contract Signed «» Suboxone or MMT - Print Path Requisition for: Methadone Set [ «» ] «» To follow up with Social Work for: - «» A & D counseling - «» Detox - «» Support Recovery - «» Harm reduction - «» 12-step program - «» Primary Care provider - «» Other: «» «» Take home naloxone kit given Follow up: «» |
| ADGI | advice given | advice given |
| ADHERENCE | Adherence Notes | Title: Adherence Plan for Client’ Receiving all Oral DAAs Currently client: Attends a daily Medication Program at PC Site: yes/no Has medications linked to ORT at a community pharmacy: yes/no & DOT/Daily Dispense Pharmacy Location details: (leave blank) Has medications linked to ARVs at a community pharmacy: yes/no & DOT/Daily Dispense/Weekly Dispense/Monthly Dispense Pharmacy Location details: (leave blank) Receives medication support via VCH STOP Outreach Team: yes/no Receives medication support via social housing organization: yes/no Details: Receives medication in bubble packaging from pharmacy: yes/no; weekly/monthly Where do opportunities for consistency lie in the client’daily routine? (please describe) leave space Challenges to adherence and risk mitigation strategies? (Leave space) Additional Support Arranged for HCV Tx Adherence: (tick box for all that apply) - Daily DOT Medication Management at PC Site - Linking HCV meds to a community pharmacy for DOT/Daily Dispensing/Weekly Dispensing Pharmacy Location Details: (leave blank) - Referral to VCH STOP Outreach Team for Medication Management Support (Co-infected clients only) - Referral to VCH STOP Prevention Case Managers (Mono-infected clients) - Referral to VCH MH and/or ACT team Details: leave blank - Coordination with social housing organization for medication management support Details: leave blank - Organized medication packaging with community pharmacy Pharmacy Location details: leave blank - Other: leave blank Recommended Frequency of check-ins with HCV Treatment Team for Monitoring & Support: Leave blank Alternative Contact and/or Location Details for client: Leave blank |
| ADIME | Dietitian Note (calls ADIMETEXT) | |
| ADIMECP | Dietitian Initial Consult (calls ADIMECPTEXT) | |
| ADIMECPTEXT | Dietitian Initial Consult (TEXT ONLY) | Assessment: Reason for assessment: «» Consent: «» Patient History: «» Medical History: «» Family History: «» Social History: «» Housing: «» Cooking facilities: «» Income: «» Community meal supports and resources accessed: «» Alcohol/Drug use: «» Mental health: «» Food and Nutrition History: «» Previous diet instruction: «» Food allergies/Intolerances: «» Diet History: «» Nutrition-focused physical findings: Appetite: «» Nausea/Vomiting/Heartburn: «» Diarrhea/Constipation: «» Dentition: «» Swallowing/Sore Mouth/Altered Taste: «» Mobility/Exercise/Functional Status: «» Fat loss: «» Muscle loss: «» Edema/ascites: «» Contributing factors (cachexia or sarcopenia): «» Anthropometrics: Height «» Weight «» BMI «» Usual body weight: «» Unintentional weight loss, 6 months: «» Percent weight change, 6 months: «» Medication: «» «Letter.Patient.UsualPrescription» Supplements: «» Labs, Medical Tests and Procedures: «» CD4: «Letter.Patient.Macro.LATESTCD4» «Letter.Patient.Macro.LASTRNA» A1C: «Letter.Patient.Macro.LATESTA1C» Random Gluc: «Letter.Patient.Macro.LASTRBS» Fasting Gluc: «Letter.Patient.Macro.LATESTFBS» Lipid Profile: «Letter.Patient.Macro.LASTLIPID» Renal function: Urea: «Letter.Patient.Macro.LASTUREA» Cr: «Letter.Patient.Macro.LATESTCREATINNE» eGFR: «Letter.Patient.Macro.LATESTGFR» Electrolytes: «Letter.Patient.Macro.LASTELECT» Hematology: Hgb: «Letter.Patient.Macro.LATESTHEMOGLOB» MCV: «Letter.Patient.Macro.LASTMCV» Hct: «Letter.Patient.Macro.LASTHEMATOCRIT» Ferritin: «Letter.Patient.Macro.LASTFERRITIN» TSaturation: «Letter.Patient.Macro.LASTTRANSFERRIT» Iron: «Letter.Patient.Macro.LASTIRON» B12: «Letter.Patient.Macro.LATESTB12» Vit D: «Letter.Patient.Macro.LASTVITD» SGA Score: «» Nutrition Status/Risk: «» Diagnosis: Problem: «» Etiology Related to: «» Signs/Symptoms as evidenced by: «» Intervention: Nutrition Goals: «» Food and/or Nutrient Recommendations: «» Nutrition Education: «» Handouts Provided: «» Coordination of Nutrition Care: «» Community Referrals: «» Forms Completed: «» Monitoring and Evaluation: «» «» |
| ADIMETEXT | Dietitian Note (TEXT ONLY) | Assessment: «» Diagnosis: «» Intervention: «» Monitoring and Evaluation: «» |
| ADM | Admin Note | |
| AGA | Adult Protection Concerns – Do Not Disclose (calls AGATEXT) | |
| AGATEXT | Adult Protection Concerns - Do Not Disclose (TEXT ONLY) | Investigation under the Adult Guardianship Act. Confidential. Do not disclose or release. |
| AH | At Home | |
| AHBTR | Acute Home Based Treatment Program (calls AHBTRTEXT) | |
| AHBTRTEXT | Acute Home Based Treatment Program (TEXT ONLY) | See documentation in form |
| ALV | AL RN visit (alv\) | AL RN visit (alv\) Reason for visit - «» «Letter.Patient.Macro.LASTRNA» «Letter.Patient.Macro.LASTCD4» Blood pressure «» O2 sat «» Pulse rate «» Recent adherence (patient report and collateral) - «» Issues and Plan - «» |
| AM | Amanda Ames Signature | Amanda Ames, MN-NP(F), MSP# 82400 Community Response Nurse Practitioner Sunshine Coast Home Care Services Cell: 604-318-9085 CRNP Intake Line: 604-885-8525 Fax: 604-741-0728 Email: amanda.ames@vch.ca |
| AN | Addiction Services Note | |
| ANGINATT | If difficulty breathing or | If difficulty breathing or chest pain 1. lay down 2. take 1 puff od nitrolingual spray under the tongue 3. IF there is immediate improvement in the breathing or chest pain then this is ok . IF it is not improving in a few minutes (few = 3 NOT 10 mins) 4. Phone 911, unlock front door , laydown and have another puff of nitrolingula spray |
| ANO | anorexic | anorexic |
| AO | ankle oedema | ankle oedema |
| AP | VCH – Revised SOAP Format | Subjective: «» Objective: «» Assessment: «» Plan: [Follow up «Letter.Patient.Next Appointment.Date»] with [«Letter.Patient.Next Appointment.ProviderName»] «» |
| APC | Counsellor Progress Report | Report Status: (remove unused option) Progress report Discharge report Source/Reason for Referral: «» Emotional and Relational Issues Identified: (patient's priority issues) «» Patient Goals: «» Progress: (Approaches and interventions implemented and recommended; Outcome measures) «» Follow-up: (remove unused options) Counselling Services Declined Ongoing Counselling Recommended for: «» Referral to Other Clinician/Service: «» Discharge from PCN Counselling Service Other: «» Additional Information: Counsellor's Name: «Letter.LoggedOnUser.FullName» Counsellor's Signature: «Letter.LoggedOnUser.Signature» Contact #: «» |
| APPT | Physiotherapy Note | |
| APPTTEXT | Physiotherpy Note (Text Only) | COVID screen: «» Consent obtained: «» Reason for referral: «» Subjective: HPI Onset: «» Location: «» Duration: «» Characteristics: «» Aggravated by: «» Relieved by: «» Red Flags: «» Lifestyle Routine: «» Activities/Hobbies: «» Mobility Aids: «» Sleep: «» Social Supports: «» Client Profile PMHx: «» Medications: «» Imaging/Investigations: «» Social Hx: «» Client Perspective Beliefs about pain: «» Current and past experiences with PT/Other Interventions: «» Goals: «» Objective: «» Assessment: «» Plan: Follow up with «Letter.LoggedOnUser.FullName»,«Letter.LoggedOnUser.JobTitle» «» |
| APS | Synopsis Tab - Alcohol (AccelEMR) | Preferred Type: «» Amount Used (mm/yy-amount/day): «» Age when started: «» Reasons to continue: «» Barriers to quitting: «» Quitting Attempts: DateDurationMethodComplications/Lessons Learned «Letter.Patient.DateLastSeen»«»«»«» «»«»«»«» «»«»«»«» «»«»«»«» «»«»«»«» Notes: «» |
| AR | ARV Refill | ARVs in Usual Meds List: «Letter.Patient.Macro.ARVMEDS» «Letter.Patient.Macro.LASTCD4» «Letter.Patient.Macro.LASTRNA» |
| ARVC | ARV Change (Calls ARVCTEXT) | |
| ARVCTEXT | ARV Change (TEXT ONLY) | Current regimen: «» New regimen: «» Reason for regimen change: «» HLA-B*5701 (date): «» HIV resistance/genotype (date): «» Adherence: «» Meds/ OTC: «Letter.Patient.UsualMedicationNameOnly» Labs/ ADR/ drug interactions: «Letter.Patient.Macro.LASTCD4» «Letter.Patient.Macro.LASTRNA» Impression/Plan: «» |
| ARVI | ARV Initiation (calls ARVITEXT) | |
| ARVITEXT | ARV Initiation (TEXT ONLY) | HIV diagnosed (date): «» HLA-B*5701 (date): «» HIV resistance/genotype (date): «» CD4 (date): «Letter.Patient.Macro.LASTCD4» HIV pVL (date): «Letter.Patient.Macro.LATESTHIVVL» Past ARV history and details (if any): «» Medical conditions (dx date if known): «» Social: «» Hepatitis serologies (date): Hep A IgG: «Letter.Patient.Macro.LATESTANTIHAV»Hep B core Ab: «Letter.Patient.Macro.LATESTHBCAB»Hep C Ab: «Letter.Patient.Macro.LASTHCAB» Hep B surface Ag: «Letter.Patient.Macro.LATESTHBSAG»Hep C RNA: «Letter.Patient.Macro.LATESTHCVRNADAT» Hep B surface Ab: «Letter.Patient.Macro.LATESTHBSAB» Hep B DNA VL: «Letter.Patient.Macro.LATESTHBVDNA» Pertinent Labs: Last Creatinine: «Letter.Patient.Macro.LATESTCREATINNE» Last GFR: «Letter.Patient.Macro.LATESTGFR» Meds/ OTC: «Letter.Patient.UsualMedicationNameOnly» Drug Interactions Assessment: «» Impression/ Plan: «» OTHER MEDICAL/MEDICATION ISSUES: «» |
| ARVR | ARV Refill (calls ARVRTEXT) | |
| ARVRTEXT | ARV Refill (TEXT ONLY) | Current regimen: «» Adherence: «» Meds/ OTC: «Letter.Patient.UsualMedicationNameOnly» Labs/ ADR/ drug interactions: «Letter.Patient.Macro.LASTCD4» «Letter.Patient.Macro.LASTRNA» Impression/Plan: «» OTHER MEDICAL/MEDICATION ISSUES: «» |
| ASARI | Assessment of Suicide and Risk Inventory (ASARI) | |
| ASMA1 | Asthma Template Visit 1 | History: «status, medication, management, or review for existing patient» Inform: «tell patient what they need to know» Assist: «what does the patient want from you» Technique: «review of technique with asthma devices» O/E: «perform physical examination, including spirometry» Grade: «severity and control» Recordings: «consider 2 weeks of peak expiration flow rate (PEFR) recording and charting» Changes: «to medications or protocol» |
| ASMA2 | Asthma Template Visit 2 | Review: «patient and PEFR records» Spirometry: «(if not already done, or consider redoing)» Action Plan: «complete written Asthma Action Plan» Triggers: «further identify trigger factors: consider RAST, skin-prick tests (if not already done)» Changes: «to medications or protocol» Education: «check on, reinforce and expand education» Questions: «Answer any questions» |
| ASMA3 | Asthma Template Visit 3 | Assess: «progress» Action Plan: «review Asthma Action Plan» Triggers: «discuss results of trigger factor tests ( if applicable)» Education: «check on, reinforce and expand education» Questions: «Answer any questions» |
| ASSURG | I am a family physician | I am a family physician specializing in care of transgender people. I have been providing gender affirming care since 2012 and providing surgical readiness assessments with the Vancouver Coastal Health Trans Specialty Clinics since 2015. |
| ASTHMA | Asthma Review | Asthma Review Peak Flow rate: «peak flow here» Respiratory rate: «RespRate» Chest Auscultation: «Chest» Inhaler Technique: «Assessment of technique» |
| ASTT | Your best Peak Flow is .. | Your best Peak Flow is .. L/min ------------------------------------------------------------------------------ When you are feeling WELL Your peak flow will be about 80% of your personal best (> …. L/min) Use your normal treatment of …………………………….. Before exercise…………………………………… ------------------------------------------------------------------------------- When you are feeling UNWELL Your peak flow will be 60- 80% of your best (…. to…. L/min) Increase your treatment to: ------------------------------------------------------------------------------- If you are GETTING WORSE Your peak flow will be 40-60% of your best (…. to…. L/min) Seek medical help -------------------------------------------------------------------------------- In an EMERGENCY Dial 911 Your peak flow will be less than 40% of your best (…. L/min) If you follow this plan but your symptoms get worse, see a doctor immediately or call an ambulance. Take this action plan with you when you visit your doctor! ASTHMA SYMPTOM SHEET --------------------------------------------------------------------------- When you are feeling WELL You should -be free of regular night-time wheeze or cough or chest tightness -have no regular wheeze or cough or chest tightness on waking or during the day -be able to take part in normal physical activity without getting asthma symptoms -need your reliever less than 3-4 times a week unless it is used before exercise. Your peak flow will be at or about your personal best. ------------------------------------------------------------------------------- When you are feeling UNWELL You will -have increasing night-time wheeze or cough or chest tightness -have symptoms regularly in the morning when you wake up -need extra dosed of reliever medication -have symptoms which interfere with exercise. (You may experience one or more of these) Your peak flow will be 60-80% of your personal best. You may see an increasing difference between morning & evening readings ( before reliever) --------------------------------------------------------------------------------- If symptoms are GETTING WORSE This is an acute attack! You will have one or more of the following: -wheeze -cough -chest tightness -shortness of breath You will need to use your reliever medication at least once every 3 hrs, or more often. Your peak flow will be 40-60% of your personal best. --------------------------------------------------------------------------------- DANGER SIGNS -your symptoms get worse very quickly -wheeze or cough or shortness of breath continue after using reliever medication or return within minutes of this. -severe shortness of breath, inability to speak comfortably, blueness of lips IMMEDIATE ACTION IS NEEDED! CALL AN AMBULANCE |
| ATT | A copy of relevant consultation records are included below. | A copy of relevant consultation records are included below. |
| ATTEMPT | Attempts to inform | Reason: «» Needs: «INFORM»«TEST/TREAT»«EPID» 1st attempt: «» 2nd attempt: «» 3rd attempt: «» |
| AUDFU | Alcohol Use Disorder Follow-Up Visit | Alcohol Use Disorder Follow Up Visit Subjective: «» Alcohol Use Status: Type of Alcohol: «» Last Ingestion: «» Has drinking decreased: Yes «» No «» #Days in last week: «» Amount each time: «» Pharmacological Management: Yes «» No «» If Yes: Medication: «» Missed Doses: «» If Yes, why? «» Any withdrawal symptoms: Yes «» No «» If Yes, symptoms: Nausea «» Vomiting «» Anxiety «» Sleep disturbance «» Hallucinations «» Headaches «» Other Substance Last Used Amount/Freq Route Other Details Heroin «» «» «» «» «Opiate» «» «» «» «» Crack Cocaine «» «» «» «» Cocaine (powder) «» «» «» «» BZD «» «» «» «» Crystal Meth «» «» «» «» «Other» «» «» «» «» Objective: Blood pressure Pulse rate Withdrawal symptoms: Yes «» No «» If Yes, symptoms: Tremor«» Diaphoresis «» Agitation «» Counseling? «» Last UDS: «Letter.Patient.Macro.LASTUDS» Assessment/Plan: «» Length of this Rx «» wk(s) Rx expires on: «» |
| AVIN | Anne Vogel Intake Note | |
| AVINTEXT | Anne Vogel Intake Note (TEXT ONLY) | Oriented to clinic services (Y/N): «» Signed consent forms (Y/N): «» Driving policy reviewed (Y/N): «» Need for outreach services (Y/N): «» MSP Active (Y/N): «» Other Teams/Workers: «» GP/Primary Care (Y/N, Where): «» Naloxone and Other HR Strategies Discussed: «» Social & Personal Hx: • «» Substance Use Hx: • «» Substance Use Tx Hx: • «» Legal Hx: • «» Allied Health Needs and Goals: • «» |
| AXHX | Providing gender affirming | Providing gender affirming care since 2012, providing surgical readiness assessments with Vancouver Coastal Health's Transgender Specialty Care clinics since 2015. |
| BA | Radiology Template - Barium Imaging (AccelEMR) | RELEVANT HISTORY/REASON FOR EXAM: «» BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| BABYTT | Baby normal | well baby normal growth and milestones fontanelle normal ears, fundi normal uvula normal HSDNM chest clear abdo soft, no masses fem pulses normal genitalia normal hips normal, no clicking feet and knee creases normal spine normal |
| BALDNESSTT | Male pattern baldness is | Male pattern baldness is common. As a doctor I try to always mention to fellow with this condition that there are legitimate treatments to slow the baldness occuring the treatments are Regain - use the strongest available -slow hair loss - Available over the counter at the pharmacist. Considered very safe, with skin reaction allergy being the only common major side effect. Propecia - this is a tablet, is expensive. I personally refer people to a skin specialist as this medication is needed long term to help control the hair loss. Dermatologists are in the best trained position to help you judge if the expense is worth it. |
| BC | Brokerage/collateral (macro only) | |
| BCCDC | BCCDC f/u | Please have client call BCCDC at 604-707-5603 to follow-up about an important health matter |
| BD | twice daily | twice daily |
| BF | breastfed | breastfed |
| BFG | breast feeding | breast feeding |
| BG | Template - BLOOD GLUCOSE (AccelEMR)(VCH/PHC EMR) | Glucometer: Glucose - «value» mmol/L Hrs pc - «# hrs since last meal» (Recorded by: «initials») |
| BIC1 | Benzathine penicillin G 2.4 million units | Benzathine penicillin G 2.4 million units in a single dose (administered into a divided dose of 1.2 million units given IM into each hip/buttock at the same visit). |
| BIC3 | Treated with Pen G (divided doses) | Benzathine penicillin G 2.4 million units in a single dose (administered into a divided dose of 1.2 million units given IM into each hip/buttock at the same visit) to be administered weekly for three weeks |
| BLY | bilaterally | bilaterally |
| BM | bowel movement | bowel movement |
| BMDT | bone density shows osteopenia ( bone density is low but not as | bone density shows osteopenia ( bone density is low but not as low as in osteoporosis) |
| BP | Blood Pressure | Blood Pressure «EnterBloodPressure» Patient Name «Letter.Patient.FullName» |
| BPDIMAGE | Body Pain Diagram Image |  |
| BPIIMAGE | Brief Pain Inventory Image |  |
| BR | breast | breast |
| BREASTEX | nipples - no skin changes no | breast exam nipples - no skin changes no lumps no lymphadenopathy |
| BREASTTT | breast exam normal, no | breast exam normal, no LNs |
| BS | bowel sounds | bowel sounds |
| BTF | bottle feeding | bottle feeding |
| BW | Blood Work | |
| BYRC | Broadway Youth Resource Centre (Macro only) | |
| CA | Contact Attempt | |
| CAGE | Template - CAGE Alcohol Screening Test (AccelEMR) | CAGE: Do you ever think about cutting down? «yes»«no» Do you get annoyed when people talk about your drinking? «yes»«no» Do you ever feel guilty about your drinking? «yes»«no» Do you ever drink in the morning? «yes»«no» |
| CALRES | call for results | call for results |
| CAM | Cambridge | Cambridge |
| CANNABIS | Cannabis Letter | To Whom It May Concern: I support my patient attempting to manage their multifactorial neuropathic pain and/or spasticity with cannabis products. My preference would be for them to use preparations that high in CBD but with low/zero THC. Yours sincerely, |
| CAP | Clozapine Altered Parameters | |
| CAR | Client arrival checklist | 1) What is your current address? - 2) What is your current phone number? - 3) What is the best way to reach you (eg. by phone, case worker, pharmacy, etc)? - (In EMR - «Letter.Patient.AddressStreet1»; «Letter.Patient.Phone1» «Letter.Patient.Phone2» «Letter.Patient.CellPhone» «Letter.Patient.EMailAddr») |
| CARRY | Carry dose given to client for partner | Treatment of contact(s) Partner unable to come to clinic for testing and treatment, and unable to be reached at this time. Carry dose given to client for partner: Medication: «» Lot number: «» Medication handout given. Aware that if partner has medication allergies, is on other medications, or has any questions, to contact clinic before taking medication. |
| CB | Cultural Broker Note | |
| CBDISABILITY | Patient Problem: | Patient Problem: INTELLECTUAL DISABILTY Goals: Ensure comfortable and happy living conditions and surroundings Needs assistance to ensure basic functional health needs are checked teeth (last done 11/7/05) Awaiting dental extractions planned «» eyes (LAST DONE 9/05) hearing (..pending at 11/05 ) skin (LAST DONE 22/4/05) feet (LAST DONE 22/4/05) diet (- home group review clued on food about 2004) Are check at least each 2 years Treatments and services: CARE PERSON to assist in tracking when these are due; referrals to these services provided by GP / GP nurse Arrangements for Treatments and Services: «» Patient Problem: MONITOR WEIGHT/ HEIGHT / BP Goals: Maintain current weight avoid any gain ensure BP remains <135/85 Treatments and services: see GP nurse each 6-9 months check measurements Arrangements for Treatments and Services: «» |
| CC | Given to Physician | Copy Given to Clinic Physician |
| CCE | Care Coordinator Note | |
| CCM | Nursing: Contraception Management (calls CCMTEXT) | |
| CCMTEXT | Nursing: Contraception Management (TEXT ONLY) | Data · Current birth control: «» · Missed doses of birth control: «none» · Medical Conditions for Self or Immediate Family: o Migraines «none» o Cancer «none» o Stroke «none» o Blood clot «none» · Medications: «none» · Tobacco Use: «» · Breastfeeding: «no» · ACHES: «none» · Contraindications to Hormonal Contraception: «none» · LNMP: «» · UPSI since LNMP: «» · BP: bp «highlight, enter value, hit enter» · STI: «» «» Action «» Plan «» |
| CCN | Care Coordination (calls CCNTEXT) | |
| CCNTEXT | Care Coordination (TEXT ONLY) | CLIENT-IDENTIFIED GOALS: «» CLIENT STRENGTHS AND SUPPORTS: «» OTHER PEOPLE AND/OR TEAMS INVOLVED IN CARE: «» CURRENT AREAS OF FOCUS: «» OUTSTANDING REQUESTS FROM HCPs: «» UPCOMING APPOINTMENTS: «» HOUSING DETAILS: «» CHILDREN/DEPENDENTS: «» INCOME SOURCE: «» HOME SUPPORT (active HSOs, PAGs): «» BEHAVIOR PLAN / SAFETY PLAN: (Yes/No, see SHx200 if so) «» OUTREACH CLIENT: (Yes/No, See SHx108 if so) «» SEXUAL HEALTH AND CONTRACEPTION Last HIV screening: «» Last syphilis screening: «» HCV status: «» Last GC/CT: «» Last pregnancy screening: «» Contraception used: (Yes/No and type) «» MENTAL HEALTH Current mental health concerns: «» Connected to Mental Health ICT or other community MH Teams: (Yes/No, which team) «» SUBSTANCE USE Substance use patterns (drug, route, frequency): «» Current OAT: «» Overdose prevention safety plan completed in last month: (yes/no) «» RECENT HOSPITALIZATIONS: «» LEGAL Current orders: «» Connected to a Parole Officer?: (Yes/No, enter contact in Care Team with client consent): «» MINISTRY APPROVALS Wound care supplies: «» Compression: «» Mobile devices: power wheelchair: «» Incontinence products: «» Nutritional supplement (Ensure): «» PRIMARY CARE AND HEALTH PROMOTION FIT test: «» Mammogram: «» Last pap: «» Medication and appointment adherence barriers: «» Overdose Prevention Safety Plan: «» Wounds: «» Nutritional needs: «» At risk of violence?: If yes, safety plan completed «» Immunization Review: <>MMR <>Pneumococcal <>Hib < Hep A <>Hep B <>Influenza <>HPV <>C19 <>Td «» |
| CCO | Care Coordinator Outreach Note | |
| CDACNE | acne | Patient Problem: ACNE Goals: Minimise acne rash and prevent recurrences, minimise likelihood of scarring Treatments and services: Topical or oral treatments as appropriate, monitoring by GP, refer to Dermatologist if necessary Arrangements for Treatments and Services: «» «» |
| CDACNERO | acne rosacea | Patient Problem: ACNE ROSACEA Goals: Minimise facial rash and prevent recurrences Treatments and services: use of topical or oral medication as appropriate, monitor response Arrangements for Treatments and Services: «» «» |
| CDACROME | acromegaly | Patient Problem: ACROMEGALY Goals: Control level of growth hormone and prevent complications Treatments and services: Medication as appropriate, monitor height, weight, hormone levels. Refer to endocrinologist if necessary. Arrangements for Treatments and Services: «» «» |
| CDADHD | adhd | Patient Problem: ADHD Goals: Enhance child's self-esteem, improve concentration and participation at school Treatments and services: Use of appropriate medication if recommended by paediatrician, monitoring for response and any side-effects Arrangements for Treatments and Services: «» «» |
| CDALCODE | alcohol dependence | Patient Problem: ALCOHOL DEPENDENCE Goals: Aim for abstinence and improved quality of life Treatments and services: Counselling and support, monitor liver function tests, participation in supervised withdrawal programme if appropriate, use of medication to assist in alcohol withdrawal or cessation Arrangements for Treatments and Services: «» «» |
| CDALCOHO | alcohol usage, excessive | Patient Problem: ALCOHOL USAGE, EXCESSIVE Goals: Decrease alcohol intake and prevent consequences arising from excess use Treatments and services: Counselling and support, monitor liver function tests, participation in supervised withdrawal programme if appropriate, use of medication to assist in alcohol withdrawal or cessation Arrangements for Treatments and Services: «» «» |
| CDC | CDC staff signature | - «Letter.LoggedOnUser.FullName» - «Letter.LoggedOnPOS.LetterheadName» on «Letter.Letter.Today» at «Letter.Letter.CurrentTime» |
| CDE | Eligibility Evaluation for Carry Doses | Form 1: Eligibility Criteria Date: The client is requesting take-home doses: «Y/N» If “No”, concisely elaborate. Has the clinical assessment determined that the client could benefit from take-home doses?: «Y/N or N/A» Support client in their self identified goals: «Y/N or N/A» Support client with attending work or school: «Y/N or N/A» Improve client engagement to treatment program: «Y/N or N/A» Are homebound due to a health status (e.g, physical disability, infectious illness): «Y/N or N/A» Guiding criteria On a therapeutic stable dose of iOAT for 3 to 6 months: «Y/N» Earlier clinical remission: «Y/N or N/A» Optional: If “Yes”, concisely elaborate. Earlier eligibility for carry doses may be considered if the client is working, is in school, or for other considerations of individual needs with a goal to improve health and life situation: «Y/N or N/A» This includes un-paid forms of labor such as, but not exclusive to, volunteer work, essential organizational, spiritual, religious, or cultural duties, care work, and/or stay at home parents. Optional: If “Yes”, concisely elaborate. Regularly attending witnessed sessions for iOAT doses or has a valid rationale for missed doses: «Y/N» For clients not attending regularly, or who have been lost to care, carry doses may be considered to improve treatment engagement: «Y/N or N/A» If “Yes”, concisely elaborate. Has the client shown post-dose complications due to dose intolerance (i.e. over sedation, seizures) within the last 3 months?: «Y/N» If “Yes”, concisely elaborate. Is the client able to administer the medication independently outside of the clinic? (i.e., self inject or with help of a peer): «Y/N» If “No”, concisely elaborate. Is the client able to safely transport, administer, and store medications and drug/injection supplies?: «Y/N» If “No”, concisely elaborate. Is the client displaying social, cognitive, and emotional stability? (e.g., general comments or concerns): «Y/N» If “No”, concisely elaborate. Caution should be exercised: If the client has a concurrent disorder that would affect their ability to self-administer their medication as directed e.g. acute psychosis or mania: «Y/N or N/A» If “Yes”, concisely elaborate. If the client is using other substances such as alcohol, stimulants, and benzodiazepines. The client may require a specialized care plan and regular reviews by the committee: «Y/N or N/A» Stable use of other substances is not in itself a contraindication to providing carry doses. If “Yes”, concisely elaborate. As a provider, is it your assessment that the client can handle the iOAT carry dose?: «Y/N» If “Yes”, concisely elaborate. Does the client meet the eligibility criteria?: «Y/N» If “Yes”, concisely elaborate. If not, is it moving to review committee?: «Y/N or N/A» |
| CDM | Historical CDM Data Entry | Historical CDM Data Entry NOTE: THESE ARE NOT CURRENT VALUES. They are historical and entered via manual transactions window. Please see the specific CDM form or Flow Sheet for associated dates. the results will also appear with correct dates, in any cumulative views. |
| CDSYPHCASE | VCH CD - Syphilis Case Follow-up | VCH CD - Syphilis Case Follow-up Informed of diagnosis: «» Syphilis/treatment counselling provided: «» List of symptoms: «» Previous syphilis history (if unknown at time of interview): «» HIV status: «» STI/HIV testing: «» PrEP if eligible: «» Vaccines as indicated (HPV, Mpox, HAV, HBV): «» Pregnancy test if indicated: «» Any children require testing?: «» |
| CDSYPHCONTACT | VCH CD - Syphilis Contact Follow-up | VCH CD - Syphilis Contact Follow-up Reviewed testing/treatment: «» List of symptoms: «» STI/HIV testing: «» PrEP if eligible: «» Vaccines as indicated (HPV, Mpox, HAV, HBV): «» If female, obtain identifers and ensure testing/treatment completed: «» Pregnancy test if indicated: «» |
| CEC | Carries Eligibility Criteria (calls CECTEXT) | |
| CECTEXT | Carries Eligibility Criteria (TEXT ONLY) | Reason for meeting Review criteria: «Y/N» Review criteria not met but admission is advised: «Y/N» Review Criteria Meeting Does the client meet criteria: «Y/N» Committee members presents: «» Who advocates/presents the case: «» Clinical assessment included: «» Treatment Outcome Profile form State: «"attached" or "reviewed"» Eligibility Form State: «"attached", or "reviewed"» Safety Concerns: «» Key strengths of the case (bullet point about what makes client a compelling case for carries program admission): Main areas needing support (bullet point): Main points discussed (bullet point): Outcome or resolution (elaborate, concisely: In the case of review of eligibility, are iOAT carries being allowed? Select 1 option and delete the remaining options: «YES; YES, with considerations (e.g., there is a special plan in place); NO, to be reviewed in a month (e.g., similar to YES with considerations, but the plan needs to be in place to move forward); NO (the circumstances impeding the iOAT carries do not seem to be able to change in the near future. Clients can always request carries if they feel things have changed)» |
| CERN | See Patient Chart in CERNER | See patient chart in CERNER UBC Alzheimer's and MS Clinics moved to CERNER on Oct 27, 2023; therefore, all patient documentation from that time onward is located in CERNER. |
| CERT | Committal | |
| CES | Crosstown Eligibility Screening (calls CESTEXT) | |
| CESTEXT | Crosstown Eligibility Screening (TEXT ONLY) | SCREENING: What is your drug of choice? How long have you been using opioids? How do you consume your opioids (IV/IM, inhalation, ingestion)? How often are you injecting? Are you able to come to the clinic up to 3x/day? Have you had past experience with OAT (eg. suboxone, methadone, kadian, fentanyl patch etc.)? Which medications have you tried? Are you currently on OAT or iOAT? Are you still interested in the Crosstown iOAT program (diacetylmorphine)? If you don’t currently inject, would you be interested in inhalable DAM if/when it becomes available? OBSERVATION/ASSESSMENT: Does client have a good understanding of intensive nature of program/requirements? Does client have visible track marks? Does client live in close proximity to Crosstown? UDS collected? In your opinion, is client at risk of health complications, overdose, or death from poisoned drug supply? Any other observations/notes? |
| CFU | Carries Follow-Up Template | Subjective: What does the patient report about their experience with carries? Benefits? Ability to meet goals? Any challenges reported? Objective: Is there evidence of functional improvement? Good indication of functional improvement? Lack of clear evidence Limited therapeutic value or problems? How long has the patient had carries of iOAT medication? What are the patient’s specific goals of therapy? Has a decision been made regarding the success of the carries trial? When? Week 4? Month 3? Is there a recent UDS on file? Any concerns? Assessment: The iOAT carry trial is considered successful «Y/N» Plan: «Follow up» with «» The trial has been considered successful: Clear benefit, with examples: Possible benefit: Areas for work: If the trial is unsuccessful, Is there a plan to discontinue the carries? Mitigate any risk? Other problem resolution? How could the patient be supported to overcome these challenges? If there is a concern, will the client be referred to the Carries Committee? Yes No, please elaborate |
| CGII | Clinical Global Impression - Improvement Scale (CGI-I) | |
| CGIS | Clinical Global Impression - Severity Scale (CGI-S) | |
| CHADS | Template - CHADS-2 Score (AccelEMR) | CHADS - 2 SCORE (risk stratification for stroke prevention in patients with Afib) Date: «Letter.Patient.DateLastSeen» Instructions: In the Scoring Table, place the point value beside each risk factor the patient has. Use the Recommendation Table to interpret results ***Only applies to NON-valvular afib - if significant mitral stenosis, prosthetic valve, hypertrophic cardiomypathy, recent MI--> full anticoagulation recommended regardless of the CHADS-2 score. Scoring Table Risk Factors Points/RF Score CHF 1 «» HTN 1 «» DM 1 «» Age>75 1 «» Stroke/TIA 2 «» TOTAL: «» Recommendation Table Totals Risk Stroke Risk/Yr Tx Suggested 0 Low 0.50% ASA 1 Med 1.5-2.5%Coumadin or dabigitran favored over ASA >2 High 5-18% Coumadin or dabigatran *Developed by BF Gage, MD et al |
| CHECK | Empanelment:CE Checklist for Clients Lost to Ca(callsCHECKTEXT) | |
| CHECKTEXT | Empanelment: CE Checklist for Clients Lost to Ca (TEXT ONLY) | Client Engagement Checklist for Clients Lost to Care Prior to inactivating client file, ensure care team has considered the following strategies: Review CareConnect to check if client is in hospital: «Y/N» Check PARIS QuickView to see if client has engaged with other community teams: «Y/N» Check pharmanet to see if any prescriptions been filled: «Y/N» Phone client’s pharmacy listed in EMR Care Team to see if they have seen client: «Y/N» Phone client’s last known phone number: «Y/N» Review with care team and consider outreach to last known address (2-person visit): «Y/N» Check with other Outreach Teams that client has previously been connected to (OOT, STOP, ACT, IHOT, etc): «Y/N» Check if client is incarcerated (via CSO or client’s Parole Officer): «Y/N» Call client’s building (if the building is staffed): ): «Y/N» Check if client deceased (Coroner, CareConnect): «Y/N» Send letter to last known address: «Y/N» If unable to contact client or client declines to continue care, either: - confirm with care team and inactivate file via Primary Care Empanelment Workflow. -create client-specific care plan for engagement in partnership with care team Client may be re-assessed for primary care criteria if they present. |
| CHY | Collateral History | |
| CIS | COVID Isolation Support | |
| CISC | COVID Isolation Support - Check-in (calls CISCTEXT) | |
| CISCTEXT | COVID Isolation Support - Check-in (TEXT ONLY) | COVID Symptoms (observable or reported): «» Safe Supply: «» Food delivery & Hygiene: «» Communication/Coordination with Community teams/MRP: «» Outstanding needs and Plan: «» |
| CISD | COVID Isolation Support - Discharge (calls CISDTEXT) | |
| CISDTEXT | COVID Isolation Support - Discharge (TEXT ONLY) | COVID-19 Testing: «Letter.Patient.Macro.LASTCOVID19» Date of Isolation: «» Clearance by public health: «»(See note on day/month/year) Follow up PC appointment: «» Prescriptions transferred: «»(name of pharmacy) Discharge location: «» Comments: «» |
| CISI | COVID Isolation Support - Intake (calls CISITEXT) | |
| CISITEXT | COVID Isolation Support - Intake (TEXT ONLY) | MRP/Community Team: «» Medical conditions: «» Date of COVID diagnosis: «» Estimated Isolation Period: «» COVID symptoms (y/n - if yes, list symptoms): «» Client Preferences for Safe Supply (Discuss directly with client): «» Any history or current OAT? (Specify if Kadian, Methadone, Suboxone - start date or length of time if details available): «» Any recent POC UDS Results?: «Letter.Patient.Macro.LASTUDS» Current Substance Use (y/n) (Include the amount used per day. i.e. uses ½ gram fent/day, 1 pt meth/day): «» Benzodiazepine: «» Opioids: «» Stimulants: «» Cannabis: «» Alcohol: «» Nicotine: «» Comments: «» Where will they be self-isolating? Any additional notes about living arrangement or building?: «» Client preferences for self-isolating (food, other comforts, med delivery including pharmacy, other)?: «» Plan of Care: «» Food delivery: «» Groceries & Hygiene Supplies: «» Safe Supply: «» Other coordination: «» |
| CISN | COVID Isolation Support - Nursing Assessment (calls CISNTEXT) | |
| CISNTEXT | COVID Isolation Support - Nursing Assessment (TEXT ONLY) | Isolation Start date: «» COVID-19 Symptoms (y/n): «» If yes, describe symptoms: Chills: «» Cough: «» Breathing - difficult or short of breath: «» Throat - sore: «» Runny nose/congestion: «» Loss of taste or smell: «» Headache: «» Muscle aches: «» Tired/fatigue - more than usual: «» Diarrhea: «» Nausea/vomiting: «» Dizziness: «» Eyes - itchy, watery, or red: «» Confusion: «» Abdominal Pain: «» Rash on skin, or discoloration of fingers or toes: «» Other: «» Objective Assessment: Vital Signs: «»Y/N Temp «» PR «» O2Sat «» RR «» BP «» Other «» Comfort Plan: Delivered food/hygiene supplies (y/n): «» Additional comfort needs: provide details: «» Safe Supply provided (y/n) (provide details, do they need more or less Safe Supply): «» Other: Anticipated Discharge from isolation date: «» Outstanding needs & plan: «» Updated Public Health Pod 1 with symptom update (y/n): «» |
| CISS | COVID Isolation Support - Safe Supply Ax (calls CISSTEXT) | |
| CISSTEXT | COVID Isolation Support - Safe Supply Assessment (TEXT ONLY) | Community Team/MRP: «» Allergies/Chronic Medical Conditions: «» Estimated Isolation Period: «» Current Substance Use (y/n): «» Benzodiazepine: «» Opioids: «» Stimulants: «» Cannabis: «» Alcohol: «» Nicotine: «» Comments: «» How often do you use?: «» How many days in the past 30 days?: «» Number of times per day?: «» How many days in the last 30 days?: «» What is your method or preferred route?: «» Do you experience withdrawal when you do not consume? (y/n): «» When does withdrawal typically begin? (How long since last use)?: «» MRP Contacted: «» Coordination Plan: «» Arrange Pharmacy delivery (y/n) & indicate which medication: «» Team Delivery (y/n) & indicate which substance: «» Naloxone training & date: «» Safe Supply Spreadsheet updated: (y/n): «» Public Health Excel Spreadsheet updated: (y/n): «» |
| CL19 | Template - CL 19 form for ICBC (AccelEMR) | MVA - CL19 (also bill MSP 13075 if non MVA-related problem addressed - document in a New Contact) Section A - Past Medical History and Other Medical Conditions Has your patient ever had symptoms and/or received treatments/medications for the area(s) injured in this accident? Describe conditions/treatment and impact, if any, on recovery. «No» Describe any factors that may impede recovery, i.e., psychosocial / addictions / anxiety / family / fitness level / employment / diet, etc. «None» Section B - Physical Examination Initial Subjective Complaints: «» Initial Objective Findings and Investigation: «» Current Subjective Complaints: «» Current Objective Findings and Investigations. Progress: See CL19 form section B «» Section D - Treatment and Return to Work Planning If work disability, what are your patient's specific duties or physical demands that cannot be performed? «NA» What other medical conditions (non MVA-related) that may cause or contribute to your patient's inability to work? «None» Type of support/service required to facilitate return to work: «None» Specific activities your patient is not able to do and estimate of the number of weeks until they are able to do these activities: «None» Additional Remarks/Comments: «None» |
| CLOZ | Clozapine Start Form | |
| CLOZM | Clozapine Vital and Adverse Effects Monitoring | |
| CLRO | Counsellor: Outreach | |
| CLW | Community Liaison Worker Note | |
| CLWO | Community Liaison Worker: Outreach | |
| CM | Template - Complete Medical - History (AccelEMR) | Complete Medical Chief Complaints: «F4» Review of Systems: «F4» All other systems negative per review of the routine health questionnaire completed by patient Behavioral Risk Factors: Diet - «F4» Exercise - «F4» Stress - «F4» Substances: Alcohol - «updated in social history tab» Drug use - «none» |
| CMF | Template (SOAP) - CM - Female (AccelEMR) | Complete Medical Chief Complaints: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «F4» Review of Systems: «F4» All other systems negative per review of the routine health questionnaire completed by patient Behavioral Risk Factors: Diet - «F4» Exercise - «F4» Stress - «F4» Substances: Alcohol - «updated in social history tab» Drug use - «none» Objective: General - normal H&Neck - normal Chest - normal CVS - normal Breasts - normal Abd - normal GU/PV - normal Derm - normal MSK - normal Neuro - normal Psych - normal Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| CMFC | Template (SOAP) - CM-CCP - Female (AccelEMR) | Complete Medical Chief Complaints: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «F4» Review of Systems: «F4» All other systems negative per review of the routine health questionnaire completed by patient Behavioral Risk Factors: Diet - «F4» Exercise - «F4» Stress - «F4» Substances: Alcohol - «updated in social history tab» Drug use - «none» COMPLEX CARE PLAN (Billing Code: 14033) Reviewed EMR (Summary, Results, Documents, Encounters) Reviewed expected outcomes (general and disease specific as per pt handout) Reviewed linkages with other health care professionals (* Add HCP to Description line) Reviewed medication issues - affordability, S.A., compliance, refills (* Add "Rx(spacebar)" to Social Problems prn) Reviewed end of life issues; Document 'MOST' category - degree of intervention, power of attorney, living will (* Type "DOI\" to Social/Risk Problem to record; Type "most" into forms prn) Reviewed educational plan (see Chronic Disease Problems - Synopsis tab) Updated patient's Personal Health Goals (* Add "Goal" to Social Problems prn) Identified Barriers to achieving goals (* Add "Barrier" to Social Problems prn) Objective: General - normal H&Neck - normal Chest - normal CVS - normal Breasts - normal Abd - normal GU/PV - normal Derm - normal MSK - normal Neuro - normal Psych - normal Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| CMFN | Template - Complete Medical - Female (default normal)(AccelEMR) | General - normal H&Neck - normal Chest - normal CVS - normal Breasts - normal Abd - normal GU/PV - normal Derm - normal MSK - normal Neuro - normal Psych - normal |
| CMHR | Community Mental Health Referral (calls CMHRTEXT) | |
| CMHRTEXT | Community Mental Health Referral (TEXT ONLY) | Community Mental Health Referral Name & Pronouns «» Referral date: «» Referral Source (Name and contact number): «» Demographics (name, gender, language): «» Primary Care Provider: «» Presenting issue/current situation: «» Does client meet all 3 criteria of most recent version of mandate? If not why are they being referred? Any function concerns? If transfer from similar team: Client priority score «» Current clinical care plan «» Psychiatric, medical & social history: «» Recent MSE: «» Medication: «» Extended Leave: «» Substance Use (Current/past): «» Allergies: «» Legal issues: «» Financial support: «» Housing: «» Current supports/resources: «» Risk assessment: Suicide, self-harm, aggression, home environment: «» Recommendations: «» |
| CMM | Template (SOAP) - CM - Male (AccelEMR) | Complete Medical Chief Complaints: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «F4» Review of Systems: «F4» All other systems negative per review of the routine health questionnaire completed by patient Behavioral Risk Factors: Diet - «F4» Exercise - «F4» Stress - «F4» Substances: Alcohol - «updated in social history tab» Drug use - «none» Objective: General - normal H&Neck - normal Chest - normal CVS - normal Abd - normal GU/PR - normal Derm - normal MSK - normal Neuro - normal Psych - normal Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| CMMC | Template (SOAP) - CM-CCP - Male (AccelEMR) | Complete Medical Chief Complaints: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «F4» Review of Systems: «F4» All other systems negative per review of the routine health questionnaire completed by patient Behavioral Risk Factors: Diet - «F4» Exercise - «F4» Stress - «F4» Substances: Alcohol - «updated in social history tab» Drug use - «none» COMPLEX CARE PLAN (Billing Code: 14033) Reviewed EMR (Summary, Results, Documents, Encounters) Reviewed expected outcomes (general and disease specific as per pt handout) Reviewed linkages with other health care professionals (* Add HCP to Description line) Reviewed medication issues - affordability, S.A., compliance, refills (* Add "Rx(spacebar)" to Social Problems prn) Reviewed end of life issues; Document 'MOST' category - degree of intervention, power of attorney, living will (* Type "DOI\" to Social/Risk Problem to record; Type "most" into forms prn) Reviewed educational plan (see Chronic Disease Problems - Synopsis tab) Updated patient's Personal Health Goals (* Add "Goal" to Social Problems prn) Identified Barriers to achieving goals (* Add "Barrier" to Social Problems prn) Objective: General - normal H&Neck - normal Chest - normal CVS - normal Abd - normal GU/PR - normal Derm - normal MSK - normal Neuro - normal Psych - normal Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| CMMN | Template - Complete Medical - Male (default nomal) (AccelEMR) | General - normal H&Neck - normal Chest - normal CVS - normal Abd - normal GU/PR - normal Derm - normal MSK - normal Neuro - normal Psych - normal |
| CMN | Case Management Note | |
| CMNO | Case Management Outreach Note | |
| CMVN | COVID Mobile Van Testing-Neg Results Follow-up (calls CMVNTEXT) | |
| CN | Counsellor Note | |
| CO | MHSU PARIS to Profile EMR Cutover | MHSU PARIS to Profile EMR Cutover Medications and allergies documented. |
| COD | Clinician of the Day to review | Clinician of the Day to review - «Letter.Letter.Today» |
| CONFIRM | PrEP enrollment confirmed | PrEP enrollment has been confirmed. Medication will be ready for pick up in 3 business days. Please note that medication must be picked up within 30 days or the prescription expires. |
| COPD | COPD annual review | COPD annual review MRC Dyspnoea scale (Grade 1-5): SpO2 if Dyspnoea scale >3: Number of exacerbations past year (antibiotics/pred required?): Number of hospital admissions past year due to COPD: Most recent Influenza vaccination: Most recent Pneumococcal vaccination/further needed?: Most recent FEV1 (consider repeating if >1 yr): Smoking cessation brief intervention if current smoker: Action plan reviewed/provided to client: |
| COPD1 | COPD Template for TBC | Subjective: • Client Goals/Primary Concern «» • Respiratory «SOB/Cough/Sputum» • ADLs/Mobility/Limitations «how far can you walk without getting SOB?» • Nutrition and Weight «» • Smoking «» • Med Review «adherence, inhaler technique» • Exacerbations «» • Action Plan «» • Mood «» Objective: • BP «» • PR «» • RR «» • o2sat «» • Wt «» • Ht «» • Resp «WOB, auscultation» • CVS «heart sounds, murmur, pedal edema» • Last PFT «» • Immunizations Flu «» Pneumovax «» Pertussis «» Assessment/Plan: 1. COPD - «» |
| COV | Opens Covid 19 Screener | |
| COVD | Discharge COVID Outreach (calls COVDTEXT) | |
| COVDTEXT | Discharge COVID Outreach (TEXT ONLY) | COVID-19 Testing: «Letter.Patient.Macro.LASTCOVID19» Date of Isolation: «» Clearance by public health: «» (See note on day/month/year) Follow up PC appointment: «» Prescriptions transferred: «» (name of pharmacy) Discharge location: «» Comments: «» |
| COVI | COVID-19 Isolation Intake (calls COVITEXT) | |
| COVITEXT | COVID-19 Isolation Intake (TEXT ONLY) | Referral Source: «» Current MRP: «Letter.Patient.DoctorUsual.FullName» Other Care Teams involved: «» COVID History: Date of first symptoms «» COVID-19 Testing: «Letter.Patient.Macro.LASTCOVID19» Contact to covid case (yes/no): «» If yes, date of last contact «» COVID-19 Symptoms (yes/no): Symptoms: «» Chills: «» Cough: «» Breathing - difficult or short of breath: «» Throat - sore: «» Runny nose/congestion: «» Loss of taste or smell: «» Headache: «» Muscle aches: «» Tired/fatigue - more than usual: «» Diarrhea: «» Nausea/vomiting: «» Dizziness: «» Eyes - itchy, watery, or red: «» Confusion: «» Abdominal Pain: «» Rash on skin, or discolouration of fingers or toes: «» Other (add in notes): «» Vital Signs when possible: temp «» pr «» o2sat «» rr «» bp «» History of the following (yes/no): Diabetes Mellitus: «» Kidney Disease: «» Liver Disease: «» Cardiovascular Disease: «» Asthma: «» Pregnancy: «» Immune Compromised: «» Other: «» Current Medications (make any updates on Usual Scripts tab) «Letter.Patient.UsualPrescriptionNameOnly» Substance Use History (yes/no/frequency): Benzodiazepine: «» Opioids: «» Stimulants: «» Alcohol: «» Nicotine: «» Comments: «» Need OAT/Safe Supply Plan (yes/no): Current OAT (Type and dosage): «» Daily Witnessed Ingestion: «» Current Prescriber: «» OAT Pharmacy: «» Comments: «» Psychosocial Needs/Current Housing status Housed (yes/no): «» If yes, where? «» Shared Kitchen/food content (yes/no): «» Shared Bathroom (yes/no): «» Pets, Partners, Children?: «» Comments: «» Plan: «» |
| COVM | COVID-19 Monitoring (calls COVMTEXT) | |
| COVMTEXT | COVID-19 Monitoring (TEXT ONLY) | PMHX: «» Subjective: «» Symptoms: «» Current risk mitigation prescribing (e,g, OAT, safe supply meds): «» Current non-medication safe supply (Nicotine, ETOH, cannabis): «» Regular/usual meds of note: «» Additional substance use in addition to risk mitigation prescribing: «» Objective: «» C19 test result/date: «Letter.Patient.Macro.LASTCOVID19» Vital signs: «» Temp «» PR «» O2Sat «» RR «» BP «» Well-appearing; NAD UDT results (if completed): «» Assessment/Impression: Plan: «» Anticipated discharge date: «TBD» Current MRP: «» Other Care Teams Involved/Active Referrals: «» Own Pharmacy (name, address, phone): «» Discharge Location: «» |
| COVP | COVID-19 Pediatric Monitoring – COVID OT (calls COVPTEXT) | |
| COVPTEXT | COVID-19 Pediatric Monitoring – COVID OT (TEXT ONLY) | COVID-19 Symptoms (yes/no): «» Cough «» Sore Throat «» Plugged/running nose «» Flaring Nose «» Breathing (yes/no): «» Grunting/stridor «» Wheezing «» Retractions/accessory muscles? «» Rapid «» Resp rate: «» (WNL = : 0-6 mo: 30-60 bpm; 6 mo-1 yr: 24-30 bpm; 1-5 yrs: 20-30 bpm) Feeding (more, less, normal) «» Diarrhea «» Vomiting «» Loss of taste or smell? «» Red or watery eyes «» Skin colour (healthy, yellow, blue) «» Rash «» Swelling «» Behaviour (yes/no): «» Headache «» Increased crying «» Decreased feeding «» Any lethargy «» Comment on any symptom present: «» Vital signs: Temp (Axillary): notable if >37.5 «» PR: «» O2Sat (if possible): «» COVID-19 Testing: «Letter.Patient.Macro.LASTCOVID19» Anticipated Discharge date: «» Outstanding needs & plan: «» |
| CPC | Template - Community Patient Conference (AccelEMR) | COMMUNITY PATIENT CONFERENCE (Bill 14016 with V15, V58 or mental illness Dx code) - Reason for Clinical Action Plan - «» - Other HCP's involved in conference - «» - Family members interviewed - «» - Reviewed comorbidities, consults and investigations - Clinical Action Plan - see Plan, Lab, Rx, Referrals - Start time - «» Stop time - «» OR See time of Encounter note and clock |
| CPL | POR Care Plan (calls CPLTEXT) | |
| CPLTEXT | POR Care Plan (TEXT ONLY) | CARE PLAN CLIENT STRENGTHS «» CLIENT SUMMARY «» SAFETY Environment «» History «» Triggers «» Signs of escalation «» Approach/intervention «» NEEDS/GOALS Housing Need: «» Goal: «» Interventions: «» Review date: «» Finances Need: «» Goal: «» Interventions: «» Review date: «» Physical Health Need: «» Goal: «» Interventions: «» Review date: «» Mental Health Need: «» Goal: «» Interventions: «» Review date: «» Education/Leisure/Employ Need: «» Goal: «» Interventions: «» Review date: «» Transportation: Need: «» Goal: «» Interventions: «» Review date: «» Social network including Family/Friends Need: «» Goal: «» Interventions: «» Review date: «» Spirituality Need: «» Goal: «» Interventions: «» Review date: «» Other Need: «» Goal: «» Interventions: «» Review date: «» |
| CPSEH | Syph Enc Hx_Zoc | Syph Enc Hx_Zoc |
| CPSSL | Syph Lab Hx_Zoc | Syph Lab Hx_Zoc |
| CPSSN | Syph Notes Hx_Zoc | Syph Notes Hx_Zoc |
| CR | MHSU Counselling Referral | Reason for Referral: «» Is the client aware and supportive of referral? «Yes/No» Client Readiness to Engage: «Low/High» Is this an Urgent Referral? «Yes/No» If Yes, rationale for urgency: «» |
| CRIE | Client Reached in Encampment | |
| CRIF | Client Reached in Forest, Car/Van, Condemned Structure | |
| CRIO | Client Reached in Other | |
| CRIS | Client Reached in Shelter | |
| CRISH | Client Reached in Supportive Housing | |
| CRIU | Client Reached in or is Underhoused/Unsafe Housing | |
| CRR | Crisis Response | |
| CS1HIV | HIV Primary Care - first visit | HIV Primary Care - first visit with MD PMH - «» Surgical hx - «» ARVs - «» Other meds - «» Adverse drug reactions - «» Social hx - «» Occupational/finances hx - «» Education - «» Family hx - «» Sexual hx - «» Diet - «» Physical activity - «» Habits tobacco smoking - «» cannabis - «» ups (crystal, crack, cocaine, etc) - «» downs (heroin, opiates, benzos) - «» party drugs (ecstasy, ketamine, GHB, etc) - «» etOH - «» Addictions hx - «» Legal hx - «» Pregnancy hx - «» HIV Date of diagnosis - «» Past ARVs - «» CD4 nadir - «» HIV genotypes - «» HLAB*5701 result - «» HIV risk factors - «» Seroconversion illness? - «» Infection screening syphilis - «» GC and chlam - «» HCV - «» HBV - «» CMV (non-IVDU non-MSM only) - «» VZV - «» TB - «» Toxo - «» Low CD4? - «consider MAC cx, crypto Ag, eye exam if 'yes'» Cervical/anal Pap - «» Bone mineral density - «» ECG to assess QTc - «» Immunizations HAV - «» HBV - «» HPV - «» Td - «» Pneumovax - «» Prevnar - «» flu - «» HZV - «» Current concerns «» Objective «looks well, physical exam deferred» Issues and Plan HIV - «» «type here» Follow-up plan: «» First visit checklist Reviewed clinic hours, MD availability, on-call line - «» Paper and electronic chart reviewed - «» Medinet reviewed - «» Care Connect reviewed - «» CfE patient profile reviewed - «» Standing order renewed? - «» Time notes (chart review and doc time: «» // face-to-face time:«») |
| CSA | Community Support Attendant Note | |
| CSCRIPT | Custom Rx Form | |
| CSI | Subjective Objective Issues and Plan | Subjective «» Objective «» Issues and Plan «» |
| CSIP | Subjective Objective Issues+Plan | Subjective «» Objective «» Issues and Plan «» |
| CSM | Consult - «Specialty» - «MD | Consult - «Specialty» - «MD Name» |
| CT | Radiology Template - CT-General (AccelEMR) | NOTE TO CLINIC: Fax Requisition RELEVANT HISTORY/REASON FOR EXAM: «» OTHER CLINICAL INFO: Prior Contrast Reaction: Yes [ ]; No [ X ] GFR: Value: «Letter.Patient.Macro.LATESTGFR» Mucomyst Rx given: Yes [ ]; No [ ] Lab Requisition for post CT Creatinine/GFR given: Yes [ ]; No [ ] NOTE TO ORDERING DOCTOR: 1) GFR must be within 3 months of test; 2) If GFR < 60: (a) Give Mucomyst Rx (b) Give Pt Req'n to repeat GFR 2 days after test BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| CTPREPFU | Refill X 90 days- script | Refill X 90 days- script given and refill faxed to BCCFE CT/GC NAAT rectum/throat collected for STI screening FU 3 months- standing lab req with monitoring |
| CTPREPS | PreP initiation Plan | PreP initiation- MD, DHall consult- form sent to BCCFE Dosing, SEs, AEs, monitoring reviewed, handout given Will text client when PreP enrollment confirmed FU 1 month- lab req given with instructions to complete 1 week prior |
| CTV | Radiology Template - CT-Spine (AccelEMR) | RELEVANT HISTORY/REASON FOR EXAM: «»; Vertebral Levels (must fill in): OTHER CLINICAL INFO: Prior Contrast Reaction: Yes [ ]; No [ X ] GFR: Value: «Letter.Patient.Macro.LATESTGFR» Mucomyst Rx given: Yes [ ]; No [ ] Lab Requisition for post CT Creatinine/GFR given: Yes [ ]; No [ ] NOTE TO ORDERING DOCTOR: 1) GFR must be within 3 months of test; 2) If GFR < 60: (a) Give Mucomyst Rx (b) Give Pt Req'n to repeat GFR 2 days after test BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| D14 | Doxycycline 100mg PO BID x 14 days | Doxycycline 100mg PO BID x 14 days |
| D28 | Doxycycline 100mg PO BID x 28 days | Doxycycline 100mg PO BID x 28 days |
| DADHS | DaDHS research study visit | DaDHS research study visit |
| DAM | Injectable Diacetylmorphine 100mg/ml | INJECTABLE DIACETYLMORPHINE 100mg/ml |
| DAMI | Injectable Diacetylmorphine Instructions | INJECTABLE DIACETYLMORPHINE 1st dose: «» mg 2nd dose: «» mg 3rd dose: «» mg All doses witnessed per OAT protocol |
| DAP | DAP Documentation Format | Data: «» Action: «» Plan: «» |
| DATE | Date and Time Stamp | «Letter.Letter.Today», «Letter.Letter.CurrentTime» |
| DC | Steps Services Discharge | |
| DCN | Discharge Note (calls DCNTEXT) | |
| DCNTEXT | Discharge Note (TEXT ONLY) | This client has been discharged from «Letter.POS.FullName». |
| DEC | Diabetes Education – Dietitian Summary | |
| DELABEL | Open Penicillin Allergy De-labeling Form | |
| DELETETX | Delete Transaction (calls DELETETXTEXT) | |
| DELETETXTEXT | Delete Transaction (TEXT ONLY) | «Name of result or document» was imported to this current client record in error and will be deleted by EMR Help. «MRP or delegate» aware. |
| DEN | Diabetes Education - Nurse Summary | |
| DHIV1 | Routine HIV Follow Up | S: Routine HIV Follow Up Adherence: «» No Missed Doses «» Missing a Few doses «» Missing Several Doses Medication Side effects: «» None «» Mild: «» Moderate: «» «» Severe: «» Energy «» Good «» Fair «» Poor Appetite «» Good «» Fair «» Poor Sleep «» Good «» Fair «» Poor Sexually Active «» Yes «» No Safer Sex Practices «» Yes «» No Recent STI screen «» Yes «» No Other issues/Concerns: «» O: Wt «» Ht «» BP «» Other VS: «» Lcd4\ Lvl\ Lgfr\ Liver Enzymes «» HEENT: «» Chest: «» CVS: «» Abd: «» GU: «» MSK: «» Integument: «» A/P 1. HIV «» Stable «» Unstable, Plan: «» Routine BW in «» months Follow Up Visit in «» months |
| DIABFOLLOW | Diabetes Outpatient Follow-up | Date: «» Client's Identified Concern(s): «» Assessment of previous self-management goal/action plan: «» Current Diabetes Medications 1. «» Quantity/Frequency: 2. «» Quantity/Frequency: 3. «» Current Insulin 1. «» Dose: 2. «» Dose: 3. «» Dose: «» Other Relevant Medications: «» Supplements: «» Bloodwork comments: «» Measurements Blood pressure: «» Random blood glucose: «» mmol/L / Time since last meal: «» hours Comments: «» SMBG Data Monitoring frequency: «» Date Range: «» acB pcB acL pcL acD pcD hs «» «» «» «» «» «» «» Comments: «» Hypoglycemia: «» Hyperglycemia: «» Flu vaccine date: «» Pneumonia vaccine date: «» Foot exam date/concerns: «» Eye exam date: «» Stressors: «» Physical activity: «» Diet «» NURSING INTERVENTION «» Plan / Recommendations: 1. «» Current Self-Management Goal / Action Plan Self-management goal: «» Action plan: «» Follow-up plan: «» Date/Time: «» |
| DIABNEW | Diabetes Outpatient Initial Consult | Client's Identified Concern(s): «» Relevant Medical Information «» Diagnostic Details Diabetes Type: «» DM Diagnosis Year: «» Social History Pharmacare: «» Extended Benefits: «» Other pertinent Details: «» Tobacco Use: «» Substance Use: «» Alcohol Use: «» Meter Certification Sent: «» Current Diabetes Medications 1. «» Quantity/Frequency: 2. «» Quantity/Frequency: 3. «» Current Insulin 1. «» Dose: 2. «» Dose: 3. «» Dose: «» Other Relevant Medications: «» Supplements: «» Bloodwork comments: «» Measurements Blood pressure: «» Random blood glucose: «» mmol/L / Time since last meal: «» hours Comments: «» SMBG Data Monitoring frequency: «» Date Range: «» acB pcB acL pcL acD pcD hs «» «» «» «» «» «» «» Comments: «» Hypoglycemia: «» Carries sugar: «» Hyperglycemia: «» Flu vaccine date: «» Pneumonia vaccine date: «» Foot exam date/concerns: «» Eye exam date: «» Stressors: «» Physical activity: «» Diet: «» NURSING INTERVENTION Plan / Recommendations: 1. «» Current Self-Management Goal / Action Plan Self-management goal: «» Action plan: «» Follow-up plan: «» |
| DICTATION | Physician Dictation Template | Dear Dr. «» I saw «Mr./Mrs./Ms.» «Letter.Patient.FullName» on «». HISTORY OF PRESENTING ILLNESS «» PAST MEDICAL HISTORY «» MEDICATIONS «Letter.Patient.UsualMedication» «» ALLERGIES «Letter.Patient.ActiveProblemsAdverse» «» SOCIAL HISTORY «» FUNCTIONAL HISTORY «» MENTAL STATUS EXAMINATION «» MOCA score «»/30 Visuospatial/executive «»/5 Naming «»/3 Digit span «»/2 Vigilance A «»/1 Serial 7s «»/3 Phrase repetition «»/2 Verbal fluency 5 words «»/1 Abstraction «»/2 Delayed recall «»/5 Orientation «»/6 PHYSICAL EXAMINATION bp «» «» RELEVANT INVESTIGATIONS «» IMPRESSION AND PLAN «» |
| DIP | Opens Diabetes in Pregnancy Follow Up form | |
| DL | RDE - Letter to Referring Physician | «Letter.Letter.Today»: Doctor Letter |
| DM | Diabetes Template for TBC | Subjective: • Client Goals/Primary Concern «» • Med Review «Current meds, adherence» • Glucometer readings «frequency and self-reported values» • Vision «last ophtho appt?» • Neuropathy «last podiatry appt?» • Wounds/Infections «» • Diet «» • Activity «» • Smoking «» • Mood «» Objective: • BP «» • Wt «» • Ht «» • Last A1C: «Letter.Patient.Macro.LATESTA1C» • Last Lipids: «Letter.Patient.Macro.LASTLIPID» • Last GFR: «Letter.Patient.Macro.LATESTGFR» • Last ACR: «Letter.Patient.Macro.LASTACR» • Lower leg/foot assessment «pulses, edema, nails, wounds, sensation» • Immunization: pneumovax 23 «», flu shot «», HAV «», HBV «», Tdap «» Assessment/Plan: 1. DM – Check interventions, next bw due «» |
| DM2SUM | Type II diabetes checklist | type II diabetes checklist (dm2sum\) Last foot check: «» Last blood glucose meter check (yearly): «» Last retinal exam: «» Vaccines (flu and pneumo): «» Last vitals: «Letter.Patient.Macro.UAZVITALS» Last A1c: «Letter.Patient.Macro.LATESTA1C» Last Lipids: «Letter.Patient.Macro.LASTLIPID» Last Creatinine: «Letter.Patient.Macro.LATESTCREATINNE» Last GFR: «Letter.Patient.Macro.LATESTGFR» Last urine ACR: «Letter.Patient.Macro.LASTACR» |
| DME | Template, Visit - Driver Medical Exam - "SAFE DRIVE" (AccelEMR) | SAFE DRIVE (From CMA Driver's guide - 8th Ed) (For link enter "drive" in provider reference search bar) Safety record regarding driving (e.g. MVA's, violations) - «no concern» Attention skills - «no concern» Family comments and observations (e.g. near MVA's, need for help, others refusing to be driven) - «no concern» Ethanol use (e.g. drinking and driving) - «no concern» Drugs and medication use (e.g. benzos, narcotics, ACh ant, antipsychotics) - «no concern» Reaction times (e.g. PD, CVA) - «no concern» Intellectual function (e.g. dementia, memory, getting lost) (MMSE: __) - «no concern» Vision (e.g. acuity, visual field, glare) - «no concern» Executive functional ability (e.g. sequencing and multitasking) - «no concern» |
| DMV | DTT Mobile Van | |
| DN | Dietitian Notes | |
| DOI | Template - End of Life (AccelEMR) | «Letter.Patient.DateLastSeen»: Discussed with - «» ; Power of Attorney - «» ; Living Will/Other - «» |
| DOXYPEP | DoxyPEP prn | Self identifies as «gbMSM, non-binary, prefers to not answer» Bacterial STI Risk: «Confirmed history of in the past 12 months, Clinically assessed increased risk of Bacterial STI» Counseled on options for obtaining rx and chose following: «enrolment in BC CfE Bacterial STI program, OR via community pharmacy of their choice» Writer discussed possible Side effects (esophagitis, photosensitivity, and on-going studies as impact on gut microbiome and possible antimicrobial resistance not yet established) Client is taking Tenofovir disoproxil fumarate/emtricitabine «and/or list of other Rx» Aware to avoid taking antacids, calcium/multivitamin supplements and dairy products with Doxycycline Discussed that there is more evidence for use of Doxycycline 200mg as PEP vs. 100mg po daily as PrEP Aware to take ASAP after unprotected sex, but within 24-72 hours after sex is reasonable for PEP Prescribed «mitte-30, 60» Aware DoxyPEP largely intended for Syphilis prevention but evidence shows reduction in projected CT infections, and to a much smaller degree vs. GC Emphasized importance of using ONLY as directed and NOT sharing with others as medically unsupervised antibiotic use can lead to serious harm (Antibiotic resistant organisms, worsening infection/condition) Advised to call clinic and book appt prior to next HIV PrEP visit when only 14 caps Doxycycline left |
| DROP | Titre dropping, continue to monitor | Titre dropping, continue to monitor |
| DRR | Documentation Released from Record | |
| DSM | Template - DSM IV-TR Codes (AccelEMR) | DSM-IV-TR Assessment Axis 1 (Psych Dx, learning disorders, substance abuse disorders): «» Axis 2 (Personality Disorders and intellectual disabilities): «» Axis 3 (Medical Conditions): «» Axis 4 (Psychosocial/Environ Factors): «» Axis 5 (GAF Score) - current: «1-100;20=hosp,30=psychotic,40=severe in multiple areas,50=severe,60=mod,70=mild» - highest level in past yr: «1-100;20=hosp,30=psychotic,40=severe in multiple areas,50=severe,60=mod,70=mild» |
| DTCI | DTES Connections Intake Screen | DTES Connections Intake Screen: Substance use: «describe opiate use, daily amount, route» Wants to be on OAT: «Methadone/Suboxone/Kadian» Lives in DTES: «Yes/No» Housing: «» Attached to other clinic/OAT prescriber: «Yes/No» Last OAT in Medinet: «dose/prescriber» Income sources: «» Outreach needs: «Yes/No» Other teams in community: «» Non-OAT medical needs: «» Pharmacy: «» Behavioural concerns/Alerts: «» Reviewed by coordinator/nursing: Yes/No Does the Client Meet mandate for DTES Connections Clinic: Yes/No If Yes: • Discussion around intake process (1-2 hrs length, seen by RN/MD/ORW, UDS, BW, sign paperwork, etc) • Transitional nature of clinic reviewed and client agrees If No: • Suggest service options «» Does clinic have capacity for walk-in intake: Yes/No If Yes: • Client to complete intake today If No: • Suggest times/dates when client may return for intake • Offer THN kit/training and HR supplies • Provide other options for possible same day OAT starts |
| DTCPI | DTES Connections Physician Intake (calls DTCPITEXT) | |
| DTCPITEXT | DTES Connections Physician Intake (TEXT ONLY) | PMhx diagnoses confirmed and updated in problem list (through CareConnect/patient history/DSM-5 criteria for SUDs) Contraception: Allergies and adverse reactions updated in the EMR Reviewed RN intake note - confirmed substance use and treatment history Reviewed with patient that DTES Connections provides substance use and related complications treatment and will need to follow up at a primary care clinic or urgent care for other medical issues Active Substance Use Disorders: Goals of SUD care: o/e: UDS review: Pregnancy test: Scoring measures (where applicable) - CIWA, PAWSS, COWS: A/P: SUD(s) treatment and follow up plan: (ensure MD coverage for next two consecutive days for outpatient AUD initiated, avoid ending scripts on weekends) Task “DTC Outreach” group for: Outpatient benzo taper - check in after a few days after dose reduction for patients who are resistant/very anxious OAT titrations: reviewed when eligible for increase Offered BBI/STI screen Provide Primary Care Sites List provided to patient (if needed) |
| DTCV | Drug Treatment Court Vancouver | |
| DTQ | Template - Desire to quit & Stage of change (1-5) (AccelEMR) | Date: Desire to quit (1 = low) - «1-10» Stage of change (1-5) - «1-5» |
| DTT | DTT Health Record remediation | «Letter.Letter.Today»: Health Record remediation. Administratively uploaded COVID-19 Testing Screening form completed at 3 Bridges COVID-19 Testing Site. |
| DTTS | DTES Testing Clinic Screening (calls DTTSTEXT) | |
| DTTSTEXT | DTES Testing Clinic Screening (TEXT ONLY) | EMR POS Used (Pender, DCHC, Sheway, Heatley, 3B, RS): «» Consents to CareConnect access: «» Consent to Housing /Primary Provider contacted re: negative result: «» Contact with anyone who has tested positive for COVID-19 in previous 14 days: «» Contact with anyone involved in a cluster at SRO, shelter, corrections, clinic: «» If yes, what shelter/facility, when did they leave; what dates did they stay; any ill roommates? «» Referral Source: «» Current MRP: «Letter.Patient.DoctorUsual.FullName» Other Care Teams involved: «» Previous COVID Result: «Letter.Patient.Macro.LASTCOVID19» Chief complaint COVID-19 Symptom Onset Date: «» Fever: «» New Cough: «» Shortness of breath: «» Muscle aches/Fatigue: «» Headache: «» Runny nose: «» Sore Throat/Painful Swallowing: «» Diarrhea: «» Nausea and vomiting: «» Loss of smell: «» Loss of appetite: «» Psychosocial Needs/Current Housing status Housed: «» Roommates? «» Shared Kitchen/food content: «» Shared Bathroom: «» Pets, Partners, Children? «» IPAC assessment status done: «» Needs relocation: «» Comments: «» Any current substance use: «» On OAT? «» In need safe supply? «» Client Instructions Advised to self-isolate (follow Self Isolation Guidance here) and when to return or what to do with worsening symptoms. Swab taken |
| DUDHS | DuDHS research study visit | DuDHS research study visit |
| DUP | Opens duplicate Rx form | |
| DWA | Detox Worker Admission Note (Calls DWATEXT) | |
| DWATEXT | Detox Worker Admission Note (TEXT ONLY) | Client presentation: Belongings: Resources and recovery goals: Any other relevant informations: Actions: |
| DWD | Detox Worker Discharge Note (Calls DWDTEXT) | |
| DWDTEXT | Detox Worker Discharge Note (TEXT ONLY) | Discharge time, location and mode of transportation: Reason for Discharge (Planned/Unplanned): Belongings: Narcan provided: Any other relevant information: |
| DWF | Detox Worker Follow-up Note (Calls DWFTEXT) | |
| DWFTEXT | Detox Worker Follow-up Note (TEXT ONLY) | Activity: Recovery and support: Any other relevant information: Actions: |
| DWN | Detox Worker Note | |
| DYD | Directions Youth Drop In Centre (Macro only) | |
| DYH | Directions Youth Haven (Macro only) | |
| DYOTR | DTES youth outreach team referral(Calls DYOTRTEXT) | |
| DYOTRTEXT | DTES youth outreach team referral(TEXT ONLY) | Referral Agent Information: Name of referral agent: << >> Referral agent’s organization and role: << >> Client Background: Client’s cultural identity: << >> Client’s source of income: << >> Client's current housing situation: << >> Referral Details: Referral Reason: << >> Client’s goals: << >> Challenges and Barriers: Barriers the client currently faces: << >> Substance Use History: Client’s current and past substance use history: << >> Client Identifiers: Client’s identifying features: << >> Frequent Locations: Client’s usual hang out spots: << >> Connections: Organizations client is connected to: << >> |
| EARPD | Emerge Addiction Recovery Program – Discharge | |
| EARPF | Emerge Addiction Recovery Program - Follow Up | |
| EARPI | Emerge Addiction Recovery Program – Intake Assessment | |
| EDV | ED/UPCC Visit Followup | |
| EIC | Estrogens/blockers informed consent | permanence including breast development, genital changes «» variable fertility changes «» possible mood changes «» impermanent muscle, skin, erection, libido, hair changes; possible weight gain or loss «» unchanged voice, hair (regrowth), bone structure «» possible dehydration, dizziness, hyperkalemia leading to arrythmia «» possible nausea or headache from estrogens «» likely inc risk such as thrombotic, CVA, MI «» likely inc risk gallstones «» possible metabolic changes such as lipids and diabetic risk «» possible risk of hyperprolactinemia «» possible increased BP «» possible increased breast cancer risk «» general long term unknown/off label use «» |
| ELHD | Extended Leave Review Panel Hearing Directive | Extended Leave Review Panel Hearing Directive |
| ELRECALL | Extended Leave Recall | |
| ELRENEW | Extended Leave Renewal | |
| EM | Eliisha Magnus Signature | Eliisha Magnus, MN-NP(F), MSP# 82427 Community Response Nurse Practitioner Sunshine Coast Home Care Services Cell: 604-318-9085 CRNP Intake Line: 604-885-8525 Fax: 604-741-0728 Email: eliisha.magnus@vch.ca |
| EMNEG | Email Results - Negative | Completed negative results template sent to consented email address |
| EMPOS | Email Results - Positive | Email sent to «email address» with instructions to call BCCDC Nurse for results |
| ENT | Ears, nose and throat | ENT: Auricles: Appropriately colored, warm,dry, and smooth anteriorly and posteriorly. They are approximately level adn symmetrical. The superior aspect of the ear is level «with or higher than» tehe outer canthus of the eyes. Their size is proportinate with no lesions, deformities, masses, or discharge. Mastoid: Non-tender bilaterally. Ear Canal: The ear canals are appropriately colored. A «large, small, medium, none» amount of cerumen is present with no discharge, lesions, or foreign bodies. Tympanic Membrane: The TM are pearly gray and shiny. The incus adn malleus are clearly defined. The cone of light is present. There is no erythema, perforation, or retraction. Hearing Tests: Auditory Acuity «normal, decreased», Weber test «Not completed, laterilization»; Rinne: «not performed, BC>AC, AC>BC» Nares: Nares are patent. Smell is intact. Light hair is present bilaterally with no discharge, erythema, ulcerations, or erythema. Septum is midline. Mucosa is pink and moist with no ulcerations or erythema. Sinuses: Frontal and maxillary sinuses are «tender, non-tender» bilaterally with «no» fullness or erythema. Tonsils: Tonsils «are, aren't» present bilaterally. Anterior adn posterior pillars are pink with «no» edema, erythema or exudate. Posterior Pharynx: Appropriate color with no lesions, erythema, edema or exudate. |
| EOPS | Episodic Overdose Prevention Service (calls EOPSTEXT) | |
| EOPSTEXT | Episodic Overdose Prevention Service (TEXT ONLY) | Pre Use:«» Level of sedation: «Alert, Drowsy» What substance client is using:«» Route: «oral, IV, IM, intranasal (inhalation is not an option)» Overdose prevention safety planning done within last month? «Y/N» (If no, consider OD prevention conversation using opsp\)Any client concerns:«» Post use:«» |
| EPID | Internal Positive (655) | Tasked to CPS-EPID Priority |
| EXC | Template - Excision (AccelEMR) | Informed consent obtained. Area infiltrated with xylocaine with epi. Skin prepped and draped in sterile fashion. Full thickness ellipse around lesion excised and sent to pathology. Closed with Prolene and dressing applied. Wound care instructions given. Remove sutures in «» days. (13620 -1st, 13621 additional lesions or 6069 if face lesion) |
| EXCDEEP | Template - Excision of deep lesion (AccelEMR) | Informed consent obtained. Area infiltrated with xylocaine with epi. Skin prepped and draped in sterile fashion. Full thickness incision made over lesion and the entire lesion removed using blunt and sharp dissection and sent to pathology. Clinically consistent with «lipoma or sebaceous cyst or other». Closed with Prolene and dressing applied. Wound care instructions given. Remove sutures in «» days. (13620) |
| EXPOS | External positive (CT/GC) | Positive; H208 sent. Tasked to CPS-EPID Pos list |
| EXPOSFTMR | External positive (CT/GC) Faxed to Medical Records | Positive; Request faxed to Medical Records. Tasked to CPS-EPID Priority |
| EXPOSN | Positive STI - No H208 | Positive; NO H208 sent. Tasked to CPS EPID Pos List |
| EXPOSNND | No New Diagnosis | No New Diagnosis? Tasked to CPS EPID Priority |
| EXPOSNPH | External positive | PH208 NOT IN. Tasked to CPS EPID Priority |
| EXPOSNTC | External Positive (CT/GC) Nurse to Call/ High Priority | Positive; Nurse to Call. Tasked to CPS-EPID Priority |
| EXSLB | External Syphilis Low Blood | External syphilis low blood. Tasked to CPS-SYPH NYD |
| F1 | Form 1: Request for Admission (Voluntary Patients) | Form 1: Request for Admission (Voluntary Patients) |
| F10 | Form 10: Warrant | Form 10: Warrant |
| F11 | Form 11: Request for Second Medical Opinion | Form 11: Request for Second Medical Opinion |
| F12 | Form 12: Medical Report (Second Medical Opinion) | Form 12: Medical Report (Second Medical Opinion) |
| F13 | Form 13: Notification to Involuntary Patient of Rights | Form 13: Notification to Involuntary Patient of Rights |
| F14 | Form 14: Notification to Involuntary Patient (<16Yrs) of Rights | Form 14: Notification to Involuntary Patient (<16Yrs) of Rights |
| F15 | Form 15: Nomination of Near Relative | Form 15: Nomination of Near Relative |
| F16 | Form 16: Notification of Near Relative (Patient <16Yrs) | Form 16: Notification of Near Relative (Patient <16Yrs) |
| F17 | Form 17: Notification to Near Relative (Discharge of Invol Pt) | Form 17: Notification to Near Relative (Discharge of Invol Pt) |
| F18 | Form 18: Notification to Near Relative (Review Panel Request) | Form 18: Notification to Near Relative (Review Panel Request) |
| F181 | Form 18.1: Notification to Near Relative (Review Panel Order) | Form 18.1: Notification to Near Relative (Review Panel Order) |
| F19 | Form 19: Certificate of Discharge | Form 19: Certificate of Discharge |
| F2 | Form 2: Consent for Treatment (Voluntary Patient) | Form 2: Consent for Treatment (Voluntary Patient) |
| F20 | Form 20: Leave Authorization | Form 20: Leave Authorization |
| F21 | Form 21: Director's Warrant (Apprehension of Patient) | Form 21: Director's Warrant (Apprehension of Patient) |
| F3 | Form 3: Renewal Certificate (Involuntary Patient <16Yrs) | Form 3: Renewal Certificate (Involuntary Patient <16Yrs) |
| F4 | Form 4: Medical Certificate (Involuntary Admission) | Form 4: Medical Certificate (Involuntary Admission) |
| F41 | Form 4.1: First Medical Certificate (Involuntary Admission) | Form 4.1: First Medical Certificate (Involuntary Admission) |
| F42 | Form 4.2: Second Medical Certificate (Involuntary Admission) | Form 4.2: Second Medical Certificate (Involuntary Admission) |
| F5 | Form 5: Consent for Treatment (Involuntary Patient) | Form 5: Consent for Treatment (Involuntary Patient) |
| F6 | Form 6: Renewal Certificate (Involuntary Patient) | Form 6: Renewal Certificate (Involuntary Patient) |
| F7 | Form 7: Application for Review Panel Hearing | Form 7: Application for Review Panel Hearing |
| F8 | Form 8: Review Panel Determination | Form 8: Review Panel Determination |
| F9 | Form 9: Application for Warrant (For Purpose of Examination) | Form 9: Application for Warrant (For Purpose of Examination) |
| FA | Foot Assessment | Foot Assessment: |
| FALL | Template, Visit - Fall (AccelEMR) | Fall Description: «» Injuries: «» Fall Risk Assessment: Falls in the past year «no» Unable to rise from chair without using arms «no» Poor gait, balance and mobility «no» Other relevant neurological issue «no» Poor vision «no» Hypotension or arrhythmias «no» Urinary frequency or toileting issues «no» Foot or footwear problems «no» Medication affecting fall risk «no» Environmental hazards «no» Multifactorial Intervention (if yes to any of above): Medication change «no» Vit D and Ca «yes» Vision assessment «no» Manage cardiac issues «no» Exercise program (weight bearing) «no» Balance and mobility aids «no» Manage foot and footwear problems «no» Modify environment «no» Senior's Clinic fall prevention referral «no» |
| FAT | Template - Assessment of Fatigue (AccelEMR) | Assessment of Fatigue: Sleep «» Snoring «» Caffeine «» Alcohol «» Happiness «» Mood «» Stressors - finances work personal «» Shift work «» Thyroid history «» |
| FCC | Family visit for child in care | |
| FHX | Risk Family History | |
| FIN | Foundry NS Intake (calls FINTEXT) | |
| FINTEXT | Foundry NS Intake (TEXT ONLY) | Referred by: «» Self: «yes/no» Other: «» School: «» High school: «yes/no» Grade: «» Learning disability: «yes/no» IEP: «yes/no» College/University: «» Full time/Part time: «» Courses/Prg: «» School counsellor/supports/case manager/peer support worker: «» Foundry mental health counsellor/iYos/psychiatrist: «» Other Services: «» Pharmacy: «» Emergency Contact: «» Previous GP: «» Specialists: «» ROI: «yes/no» HPI: «» Allergies: «» Meds: «» PMH: «» HEENT: «» RESP: «» CVS: «» MSK: «» GI/GU (eating): «» GYNY: «» · Preferred gender and pronoun identification: «» · Sexual Health/orientation: «» · Contraception/pregnancy hx: «» · LMP: «» · last STI testing: «» PAP: «» NEURO MENTAL HEALTH: anxiety «» depression «» bipolar «» schizophrenia «» ADHD/ADD «» PTSD «» sigecaps: «» SUBSTANCE USE: «yes/no» Tobacco: «yes/no» #/day, years «» Marijuana: «yes/no» amount/day «» Alcohol: «yes/no» #/day «» Cocaine: «yes/no» «nasal/smoke» amt/day «» Other: «» IV «yes/no» Crystal Meth: «» Opiates: «yes/no» type: «» route: «» daily amount: «» ORT: «suboxone/methadone» Naloxone kit: «yes/no» PSHx: «» FAMILY Hx: Mother «» Father «» Siblings «» SOCIAL HX: Housing: «» Lives with: «» Safety: «» Family/supports/Friends: «» Financial: «» Job/position/hours worked «» Making ends meet? «yes/no» Tax form done: «yes/no» Activities/sports/interests/exercise: «» Driving? «» |
| FOB | Template - Fecal Occult Blood (AccelEMR) | Fecal Occult Blood FOB: «enter # of positive tests (ie 0,1,2 or 3) » /3 Positive - Note: If any are positive, send task to MD and highlight result and press F8 2x (to make red) |
| FORM21 | Form 21 - Extended Leave Recall (calls FORM21TEXT) | |
| FORM21TEXT | Form 21 - Extended Leave Recall (TEXT ONLY) | VPD File #«» Presenting Concern: «» Current Mental Status: «» Current Working Diagnosis: «» Medications: «» Extended Leave - Form 6 Expiry: «» Risk behaviours: Alcohol/Drug Use: «» Violence: «» Suicide/Homicide: «» Other: «» Goals for treatment: «» |
| FOU | Follow-up | |
| FPA | FTYL Patch Nursing Assessment (calls FPATEXT) | |
| FPATEXT | FTYL Patch Nursing Assessment (TEXT ONLY) | FTYL Patch Nursing Assessment S: - Last drug use and amount: «» - Last alcohol use and amount: «» - Amount /Quality of sleep: «adequate/inadequate» - Mood: «» O: - General appearance: «» - Level of Consciousness: «Alert/Drowsy» - Vital Signs: Temp «» BP «» RR «» PR «» O2Sat «» - Weight (once weekly): «» - Pupil size: «pinpointed/normal/dilated» - Smell of alcohol «yes/no» A: - Number of patch removed today: «» - Previous patches are present and intact: «yes/no» - If no, document description and notify physician: «» - Any withdrawal symptoms: «yes/no» - If yes, document description and notify physician: «» - Dose tolerated well: «yes/no» - If no, document description and notify physician: «» P: - Dose and number of patch applied today: «» - Patch site(s) applied (note: rotation application sites): «» - Date participant to return for next patch change: «» - HR teaching (THN, etc.): «» - Any follow up required: «» |
| FPT | Fentanyl Patch Dose Schedule | |
| FR | Template - Fall Risk Assessment (AccelEMR) | Fall Risk Assessment (review annually) Falls in the past year «no» Unable to rise from chair without using arms «no» Poor gait, balance and mobility «no» Other relevant neurological issue «no» Poor vision «no» Hypotension or arrhythmias «no» Urinary frequency or toileting issues «no» Foot or footwear problems «no» Medication affecting fall risk «no» Environmental hazards «no» Multifactorial Intervention (if yes to any of above): Medication change «no» Vit D and Ca «yes» Vision assessment «no» Manage cardiac issues «no» Exercise program (weight bearing) «no» Balance and mobility aids «no» Manage foot and footwear problems «no» Modify environment «no» Senior's Clinic fall prevention referral «no» |
| FRA | Template - Frailty Assessment (AccelEMR) | Identify frail patients and those at risk for frailty • Office visits are opportunities to engage in care planning and to identify a patient’s follow-up needs. • Suspect frailty with non-specific concerns such as: difficulty managing activities of daily living (ADL), unintentional weight loss, gradual onset of fatigue or loss of energy, recent falls or fear of falling, memory loss, and/or concerns expressed by the family/caregiver(s). |
| FRENH | FR Enhanced Care Client | This client has been identified as an Enhanced Care Client. Please go to the Yellow Patient Identifier Panel: 1. Click on ALT POS 2. Remove Care Status in Free Text Box 3. Add Enhance Care to Free Text Box |
| FREPI | FR Episodic Care Status | This client has been identified as an Episodic Care Client. Please go to the Yellow Patient Identifier Panel: 1. Click on ALT POS 2. Remove Care Status in Free Text Box 3. Add Episodic Care to Free Text Box |
| FRINTAKE | Foundry Richmond Intake Form | |
| FRLONG | FR Longitudinal Care Status | This client has been identified as a Longitudinal Care Client. Please go to the Yellow Patient Identifier Panel: 1. Click on ALT POS 2. Untick Foundry Richmond from ALT POS 3. Remove Information from Free Text Box 4. Add Foundry Richmond To PC POS 5. Add Client MRP: «Enter MRP Name here» |
| FVGA | FVG Mental Health Assessment | Current primary care provider: «» Mental health team/psychiatrist: «» Social history: Current living situation: «» Support/family: «» Finances: «» Baseline Functioning: «» Work /Education: «» Relationships: «» HPI: «» Mood disorders: «» Depression «» Anxiety: «GAD/OCD/ Phobias/ PTSD» Bipolar «» Previous SI attempts «» Substances use (type of drug, first use, current amount/how they are using): Opioids «» Stimulants «» Marijuana «» Alcohol «» Nicotine «» Benzodiazapines «» Other drugs «» Past Psych History: Hospitalizations «» Med trials «» Physical health history: «» Medications: «» Allergies: «» Family history: «» Mental Status Exam: Appearance, Behaviour «» Accessible, Reliable, rapport «» Speech «» Reported mood: «» Affect «» Thought Form «» Thought Content: «» SI/HI: «» Perceptual Disturbances «» Insight/ Judgement «» Cognition «» Assessment\Plan: «» |
| FVGI | FVG Mental Health Intake | Mental Health Intake Name: «» Preferred name: «» Pronouns: «» Gender: «M/F/Other» Next of Kin (relationship to client) and contact information: «» Primary Language: «» Interpreter required? «» Canadian citizenship: «» Extended health benefits «Y/N» Plan G Coverage «Y/N» Plan W Coverage «Y/N» Referring Source if applicable (name, phone, fax): «» Primary Care Physician or Nurse Practitioner if applicable (name, phone, fax): «» Referral Reason & Goals for Treatment: «» Presenting Problem: «» Mental Health Diagnosis (including hospitalizations/treatment course): «» Substance Use: «» Medical/Physical health diagnosis: «» Family history: «» Medications: «» Allergies: «» Special Authority: «Name of medication/s» Social history HEADSS (Drugs– see previous page): «» Home (who lives with patient, shelter, supports etc): «» Education/employment (income assistance, finances, MCFD involvement?): «» Activities: «» Sexual history: «» Risk Assessment: Suicidality/self harm? «» Recent history/past history «» Legal Charges/Involvement: «» Collateral information: «» • Past involvement with a Mental Health team: «look at PARIS for any assessments, referrals and case notes and summarize same» • A Care connect review: «summarize any hospitalizations; concentrate on psychiatric admissions» •« Print out most recent psych discharge note and get it scanned into EMR if you feel it is helpful for doctor to know» • Medinet review: «review current meds and list» • Review EMR: «summarize client’s EMR encounters as you see pertinent to consult/Intake» • Request of information from previous medical providers «» |
| FVGO | Foundry New Substance Use Intake (calls FVGOTEXT) | |
| FVGOTEXT | Foundry New Substance Use Intake (TEXT ONLY) | Foundry New Substance Use Intake Name: «Letter.Patient.FullName» Preferred name: «Letter.Patient.PreferredName» «» Pronouns: «» Gender: «Letter.Patient.Sex» «» Email: «Letter.Patient.EMailAddr» «» Best place/s to find patient: «» Next of Kin (relationship to client) and contact information: «» Referring Source if applicable (name, phone, fax): «» Primary Care Provider (name, phone, fax): «» Other Providers: «» Presenting Problem/s: «» Substance Use History Is patient on OAT: «yes/no» Is patient on risk mitigation: «yes/no» OAT (Type and dosage): «» Current Prescriber: «» OAT Pharmacy: «» Comments: «» Substance Use History (Route/frequency/What age did you start?): Benzodiazepine: «» Opioids: «» Stimulants: «» Alcohol: «» Nicotine: «» Cannabis: «» Other: «» Comments: «» How many overdoses have you had in the last 30 days?: «» Take Home Naloxone /Narcan trained: «» Aware of InSite/OPS: «» Access to Harm Reduction Supplies/Education: «» RAAC/DTC: «» Mental Health History Mental Health Diagnosis (including hospitalizations/treatment course): «» Risk Assessment: Suicidality/self harm? «» Recent history/past history: «» A Care connect review: «summarize any hospitalizations; concentrate on psychiatric admissions» Past involvement with a Mental Health team: «look at PARIS for any assessments, referrals and case notes and summarize same» «Print out most recent psych discharge note and get it scanned into EMR if you feel it is helpful for doctor to know» Medical/Physical Health Medical/Physical health diagnosis: «» Family history: «» Medications: «» «Letter.Patient.CurrentPrescription» Medinet review: «review current meds and list» Allergies: «Letter.Patient.ActiveProblemsAdverse» «» Special Authority: «Name of medication/s» Social History HEADSS (Drugs– see previous page): «» Home (who lives with patient, shelter, supports etc): «» Education/employment (income assistance, finances, MCFD involvement?): «» Activities: «» Sexual history: «» Legal Charges/Involvement: «» Physical Exam/Investigations Vital Signs Temperature «» Pulse rate «» Respiratory rate «» SpO2% «» Blood pressure «» UDS Complete «yes/no» «Letter.Patient.Macro.LASTUDS» Urine Pregnancy test complete (if applicable) «» OAT intake bloodwork complete «» Plan/Follow up: «» |
| FVGR | FVG Weekly Rounds (calls FVGRTEXT) | |
| FVGRTEXT | FVG Weekly Rounds (TEXT ONLY) | 1. Current Presentation: a. Suicide/Safety b. Mental Health c. Substance Use d. Neurodevelopment e. Sexual & Trans Health f. Physical Health g. Extended leave h. Medications i. Psychosocial 2. Transition Planning: a. Mental Health b. Substance Use c. Housing d. Finances e. Life Skills f. Employment & Education g. Resources & Supports 3. Goals/Priorities: |
| GAC | Gender Affirming Post-Operative Care | |
| GAR | Care 4 Newcomers - Adult Intake (calls GARTEXT) | |
| GARP | Care 4 Newcomers - Pediatric Intake (calls GARPTEXT) | |
| GARPTEXT | Care 4 Newcomers - Pediatric Intake (TEXT ONLY) | Care 4 Newcomers - Pediatric Intake GAR: «» Country of origin: «» Arriving from which country: «» Ht/Wt: «» Vitals: «» Age: «» Language: «» Allergy status: «» Current medications: «» Past surgeries: «» Past hospitalizations: «» Chronic health concerns: «» Current medical concerns: «» Developmental concerns:: «» |
| GARTEXT | Care 4 Newcomers - Adult Intake (TEXT ONLY) | Care 4 Newcomers - Adult Intake GAR: «» Country of origin: «» Arriving from which country: «» Vitals: «» Age: «» Language: «» Allergy status: «» Current medications: «» Past surgeries: «» Past hospitalizations: «» Chronic health concerns: «» Current medical concerns: «» Contraception: «» |
| GCO | Get Checked Online | Get Checked Online |
| GCOFU | GCO Follow-up for Positive Results | Reminder: sign lab result in EMR Received positive result for Get Checked Online client: «CT»«GC»«Syphilis»«other» Inform client: «phone call - able to contact»«unable to contact by phone; GCO client notification sent to "Please contact us"» Client education as per STI DST HIV PrEP: «N/A» «on PrEP» «Discussed; plan:» «Declined; reasons:» Treatment Plan: «BCCDC 655 Clinic: EPID appointment booked»«Follow-up with GCO partner clinic»«Follow-up with GP/other clinic:» Confirm Treatment: «client will call us»«tasked to EPID to confirm treatment» Partner notification: «client will inform partner(s)»«requests PHN to assistance»«For VIHA/IHA partner notification: H219 faxed to CD Unit» Lab result faxed to health authority CD Unit: «VCH» |
| GCOPOS | GCO Positive (CT/GC) | GCO Positive. Tasked to CPS-EPID Priority |
| GCOSR | GCO Specimen Rejection | GCO Specimen Rejection. Reason: «» «Urine received in the collection container (failure to transfer uring to Aptima tube» «Specimen leaked in transit; potential contamination» «Incorrect collection swab (cleaning swab versus Aptima kit swab» Phone call to client to notify re: error and discuss retesting options. V/M left re: nature of error LifeLabs location: «» Email sent to GCO Supervisor and Lifelabs to follow-up |
| GCOSYPH | Syph GCO Typing Template | GCO Client Previously positive syphilis? «Yes/No» Yes, return to clerical to send email No, «» |
| GCSUS | GC Susceptibility Results | GC Susceptibility. Tasked to CPS-EPID Priority |
| GCSUSE | GC Susceptibility Email | GC Susceptibility e-mail sent. Tasked to CPS-EPID Priority |
| GENAD | Genetics - Alzheimer Disease | Etiology of Dementia We reviewed how there are several causes of memory loss and/or dementia, including neurodegenerative memory disorders such as AD, cerebrovascular disease, chronic alcoholism, head injury, and other conditions. We reviewed the hallmark plaque and tangle pathology of AD and noted that this pathology begins to appear up to 15-20 years prior to any obvious clinical AD symptoms. Biomarker research will likely one day lead to early detection of AD pathology via neuroimaging, bloodwork, and/or cerebral spinal fluid sampling; at this time, however, the diagnosis of AD and other neurodegenerative diseases can only be confirmed by post-mortem brain autopsy. In the absence of medical records/autopsy reports pertaining to «Letter.Patient.FullName»’s reportedly affected relatives, the etiology of their reported dementia cannot be determined with any certainty. We noted the significant confounders of «» in «his/her». We also noted the high prevalence of AD and vascular dementia in elderly populations. Genetics of AD Sporadic AD We reviewed how sporadic AD accounts for approximately 75-95% of all AD cases. This common form of AD is caused by a combination of both genetic and environmental factors (i.e. multifactorial inheritance). Although sporadic AD does not typically run in families, empiric studies suggest that the recurrence risk for first-degree relatives of affected individuals is approximately 15-30%. (The lifetime population risk of developing sporadic AD in the absence of a significant family history is about 6-8%.) The single greatest risk factor for developing sporadic AD is aging. However, sporadic AD can occur as an early (<60-65) or late (>60-65) onset condition. Keeping the mind stimulated, avoiding head injury, reducing vascular disease risk factors, and effective management of mood disorders have been shown in some studies to decrease the likelihood of developing sporadic AD. We reviewed how several genes have been identified as susceptibility genes for sporadic AD. Variations in these genes have been shown to possibly increase or decrease a person’s likelihood of developing AD in their lifetime, but do not directly cause or prevent AD. We reviewed how the APOE gene has been identified as one of these AD susceptibility genes. Although individuals who carry one or two copies of the “high-risk” APOE4 gene have an increased likelihood of developing AD as compared to the general population, we emphasized that individuals carrying one or two copies of the high-risk APOE4 gene might never develop AD. Upon request, we reviewed more specifically how research suggests that individuals with one copy of APOE4 may have up to three times the population risk of developing AD in their lifetime; individuals with two copies may have up to eight times the population risk. These risk estimates vary from study to study. Given its limited clinical utility, genetic testing for APOE status is not clinically recommended as a means of diagnosing sporadic AD or predicting who will develop it in the future. Pursuit of such testing via on-line direct-to-consumer genetics laboratories such as 23 and Me should be approached with caution and recognition of test limitations and implications. Familial AD Rare cases of familial AD are only suspected in individuals who have a strong family history of AD onsetting at similar ages over several generations. Familial AD occurs as the result of single gene mutations that can be passed on directly from one generation to the next in accordance with an autosomal dominant inheritance pattern. If an individual has this type of familial AD, each of «his/her» children has a 50% chance of inheriting the disease-causing gene and subsequently developing AD. Familial AD can occur as an early-onset (<60-65) or late-onset (>60-65) condition. We reviewed how three genes have been identified as causative genes for some cases of early-onset familial AD (EOFAD). Clinical genetic testing for familial AD is relevant/available to a small group of individuals who meet criteria for this rare AD subtype. No genes have yet been identified as causative genes for late-onset familial AD (LOFAD). Recurrence Risk Assessment (Option 1: Sporadic AD) We discussed how, with the information available, «Letter.Patient.FullName»’s family history is not suggestive of familial AD, given «his/her» apparently negative family history of this condition. In the event that she has sporadic AD, recurrence risks for his children would be higher than the population risks for this condition, but it may be possible to mitigate their genetic predisposition to AD through lifestyle/environmental factors. «Letter.Patient.FullName» appeared reassured by the recurrence risk information presented today. We discussed how «his/her» children and siblings should promote healthy brain aging through mental stimulation, reducing vascular disease risk factors, avoiding a head injury, and effective management of stress and mood disorders. Recurrence Risk Assessment (Option 2: Cluster of Sporadic AD or Various Dementia Etiologies) In the absence of medical records/autopsy reports pertaining to «Letter.Patient.FullName»’s reportedly affected relatives, we are unable to know for certain if «his/her» own diagnosis of AD and «his/her» family history of dementia are at all related. Our interpretation of the family history is further limited by «». Nonetheless, we emphasized the confounders of «» in «Letter.Patient.FullName»’s «», «his/her» relatives’ later ages-of-onset and the population prevalence of sporadic AD in older populations, and the lack of reported dementia in «». Although we cannot rule out the possibility that «Letter.Patient.FullName» has FAD with absolute certainty, we discussed how it is most likely that «his/her» family history represents a cluster of dementia cases with different etiologies or a cluster of sporadic AD cases. In the event that «Letter.Patient.FullName» has sporadic AD and all other relatives had dementia due to different etiologies, recurrence risks for «his/her» children would be approximately 15-30%, as outlined above. In the event that both «Letter.Patient.FullName» and «his/her» «» have/had sporadic AD, recurrence risks for «his/her» children would be increased above this value but remain less than 50%, in accordance with principles of multifactorial inheritance. In either of these scenarios, it may be possible to mitigate genetic predisposition to AD through lifestyle/environmental factors. «Letter.Patient.FullName» appeared reassured by the recurrence risk information presented today. We discussed how «his/her» children should promote healthy brain aging through mental stimulation, reducing vascular disease risk factors, avoiding a head injury, and effective management of mood disorders. Recurrence Risk (Option 3: EOFAD) We acknowledged that, with the information available to us today, it is possible that «Letter.Patient.FullName»’s family history represents a case of EOFAD. In the event that «Letter.Patient.FullName» has EOFAD, the likelihood for each of «his/her» children/siblings to develop this condition could be as high as 50%, in accordance with autosomal dominant inheritance patterns. We would not expect their AD symptoms to onset any earlier than what has already been observed in other relatives. «Letter.Patient.FullName» was understandably distressed by the recurrence risk information presented today. We emphasized that our interpretation of «Letter.Patient.FullName»’s family history will be greatly aided by receipt of «his/her» affected relatives’ medical records. We discussed how «Letter.Patient.FullName»’s relatives can promote healthy brain aging through mental stimulation, reducing vascular disease risk factors, avoiding a head injury, and effective management of stress and mood disorders. We acknowledged that these extrinsic factors have not been shown to have a dramatic effect on disease onset or progression in EOFAD gene mutation carriers; however, research in this area is ongoing. Genetic Testing (Option 1: No Testing) Given that «Letter.Patient.FullName»’s family history is not suggestive of EOFAD, genetic testing for this condition is not relevant for this family at this time. Genetic Testing (Option 2: EOFAD) Upon request, we briefly reviewed how clinical genetic analysis of the three EOFAD genes is available at out-of-province laboratories. The cost of such testing is approximately $2200.00 CAN and is typically not covered by MSP. We reviewed how any EOFAD genetic testing in this family would begin with the analysis of a DNA sample from «Letter.Patient.FullName». The identification of an EOFAD gene mutation in «Letter.Patient.FullName» would confirm she has EOFAD and would likewise confirm that each of «his/her» children and siblings have a 50% likelihood of developing EOFAD in the future. The option of predictive genetic testing would be available to these relatives upon request. A negative EOFAD genetic test result would not rule out the possibility that «Letter.Patient.FullName» has EOFAD caused by a mutation in a gene that has yet to be identified. Additional genetic testing options may become available in the future. We reviewed how both diagnostic and presymptomatic genetic testing require additional pre-test genetic counselling sessions in order to ensure completed understanding of all psychological, social, legal, medical, and insurance implications. Some of the potential insurance and psychosocial implications were reviewed today. «Letter.Patient.FullName» and «his/her» family members will consider the option of pursuing EOFAD genetic testing for the time-being. New family history information, genetic discoveries, or AD therapies might warrant a review of genetic testing options in the future, and such testing can be initiated at any time upon request. |
| GENOD | Genetics - Other Diagnosis | Mood Disorders/Mental Illness We discussed the reported family history of mood disorders/mental illness. These conditions are usually caused by a combination of genetic susceptibility and environmental factors, and are often seen to cluster in families. Empiric studies suggest that close relatives of individuals with a mood disorder/mental illness have an increased likelihood of developing these conditions as compared to the population risk. We encouraged «Letter.Patient.FullName» and «his/her» relatives to be mindful of their mood and inform their health care providers of their family history of mood disorders/mental illness in order to ensure appropriate clinical monitoring. If «Letter.Patient.FullName» and/or «his/her» relatives are concerned about the family history of mood disorders, additional genetic counselling is available through the Adapt Clinic at the BC Children’s Hospital and information regarding this service was provided. Breast/Colon Cancer We discussed the reported family history of breast/colon cancer. Given that breast/colon cancer is sometimes seen to cluster in families, it would be important for «Letter.Patient.FullName» to inform «his/her» family doctor of «his/her» family history of breast/colon cancer in order to ensure appropriate clinical monitoring for this condition. «Letter.Patient.FullName» reported that «she/he» already follows recommended breast/colon cancer screening guidelines. If «Letter.Patient.FullName» or «his/her» relatives are concerned about their family history of cancer, additional genetic counselling is available through the Hereditary Cancer Program at the BC Cancer Agency and information regarding this service was provided. Cardio/Cerebrovascular Disease We discussed the reported family history of cardio/cerebrovascular disease. These conditions are usually caused by a combination of genetic susceptibility and environmental factors, and are often seen to cluster in families. Empiric studies suggest that the close relatives of individuals with cardio/cerebrovascular disease have an increased likelihood of developing these conditions, as compared to the population risk. It would therefore be important for «Letter.Patient.FullName» and «his/her» relatives to inform their health care providers of their family history of cardio/cerebrovascular disease in order to ensure appropriate clinical monitoring. Diabetes We discussed the reported family history of diabetes. Diabetes is usually caused by a combination of genetic susceptibility and environmental factors and is often seen to cluster in families. We encouraged «Letter.Patient.FullName» and «his/her» relatives to discuss their family history of diabetes with their family physicians in order to ensure appropriate clinical monitoring. Thyroid Disease We discussed the reported family history of thyroid disease. Thyroid disease and other autoimmune disorders are usually caused by a combination of genetic susceptibility and environmental factors and are often seen to cluster in families. We encouraged «Letter.Patient.FullName» and «his/her» relatives to discuss their family history of thyroid disease with their family physicians in order to ensure appropriate clinical monitoring. |
| GESTN | NDE Gestational Class Report | Gestational Diabetes Education Visit Date: «Letter.Letter.Today» Today your client attended a group education session led by a diabetes nurse and dietitian on our Gestational Diabetes team. The following content was covered during the group session: Client provided with and taught to use a blood glucose meter to check blood glucose ac breakfast, and 1 hour after each of breakfast, lunch and dinner: Goal of blood glucose results ac breakfast less than 5.3 mmol/L Goal of blood glucose results 1 hr pc meals less than 7.8 mmol./L Client verbally agreed to using OneTouch Reveal meter with mobile app while active in our program, and to share their data by pairing their meter/app with our Clinic. Set-up instructions and how to enter data on the app were reviewed. Clinic access to client’s data via mobile app will end at program discharge. Clinic expectations were reviewed including when to contact our team outside of scheduled clinic appointments: unexplained high blood sugars (i.e. consistent pattern, 3 in a row) >1 low blood sugar episode per week consistent medium to large urine ketones (> 3 positive ketone a week) If experiencing nausea, vomiting, bleeding, client advised to call OB or go to ER. Client also advised not to rely on email communication with our team in an urgent or emergency situation, as we may not immediately receive or be able to respond to email in a timely manner. Nursing plan/recommendations: Monitor blood glucose 4/day, FBG and 1 hour after Breakfast, lunch and dinner or as advised by physician and/or nurse. Regularly sync data on the OneTouch Reveal app for evaluation next visit. 2. Be active 10-15 minutes after eating and/or for 30 minutes daily and enter daily activity into the OneTouch Reveal mobile app for evaluation next visit. 3. Pharmacare certificate issued with expiry of «» Nutrition education was provided regarding healthy eating to promote adequate nutrition intake without ketosis, achievement of glycemic goals, and appropriate fetal growth and maternal weight gain. Nutrition plan/recommendations: Moderate carbohydrate intake spread over three balanced meals and two or more snacks, including a bedtime snack. Using “Beyond the Basics" (Diabetes Canada) meal planner, limit carbohydrate to 30g breakfast, 15g AM snack, 45-60g lunch, 15g PM snack, 45-60g dinner, and 15-30g bedtime snack. Check urine ketones every morning ac breakfast. Goal result is negative. If results are normal, ketone testing will be reduced to 1-2 days per week. Choose low glycemic index carbohydrates. Maintain food records using the OneTouch Reveal mobile app for evaluation next visit. Follow Up: Client verbally agreed to virtual follow-up visits with our clinic: «Y/N» «» Endocrinologist consult will be scheduled for their first follow-up visit with our clinic. Gestational Diabetes team will continue to follow every 1-3 weeks as needed, until approximately 36 weeks gestational age. Client will then be provided instructions for the remainder of their pregnancy as well as post-partum recommendations. Group facilitated by: RN: «» RD: «» |
| GOC | Advanced CarePlan / Goals of Care (calls GOCTEXT) | |
| GOCTEXT | Advanced CarePlan / Goals of Care (TEXT ONLY) | REASON(S) FOR GOALS OF CARE CONVERSATION (may list indicators such as Surprise Question, Clinical Frailty Scale, SPICT Indicators or others): «» CONVERSATION DETAILS Set-Up: «» Permission given by client? «Yes/ No» Client's illness understanding: «» Amount of information desired: «» Medical history/prognosis explained by health care team: «» Key Topics: Goals/priorities if sticker: «» Fears/worries about future: «» Sources of strength: «» Everyday abilities not wanting to lose: «» Trade-offs willing to go through: «» People closest to client and their awareness of above wishes: «» Summary/ Recommendations: Key points important to client (list below): «» Key recommendations given to client (list below): «» |
| GREIG10 | Greig Health Record: Age 10 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Trampoline Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG11 | Greig Health Record: Age 11 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Trampoline Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG12 | Greig Health Record: Age 12 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Trampoline Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG13 | Greig Health Record: Age 13 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Trampoline Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG14 | Greig Health Record: Age 14 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Workplace: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations dTap Rubella titre (female only) Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG15 | Greig Health Record: Age 15 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Workplace: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations dTap Rubella titre (female only) Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG16 | Greig Health Record: Age 16 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Workplace: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations dTap Rubella titre (female only) Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG17 | Greig Health Record: Age 17 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» ***Psychosocial history and Development (HEADSSS) School & Activities: «» Peer relationships: «» Family relationships: «» ***Mental Health: «» *Body changes: «» ***Sexual health: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Helmet safety: «» Vehicle Safety & Seatbelts: «» Violence and Firearms: «» Workplace: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Head & Neck: «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations Rubella titre (female only) Meningococcal, Hep B HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG6 | Greig Health Record: Age 6 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» Psychosocial history and Development School & Activities: «» Peer relationships: «» Family relationships: «» *Body changes: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety - Seatbelts, Booster Seats: «» Violence and Firearms: «» Trampoline Safety: «» Water Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations DTaP-IPV (age 4-6) MMR (2nd dose by age 6) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG7 | Greig Health Record: Age 7 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» Psychosocial history and Development School & Activities: «» Peer relationships: «» Family relationships: «» *Body changes: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety - Seatbelts, Booster Seats: «» Violence and Firearms: «» Trampoline Safety: «» Water Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG8 | Greig Health Record: Age 8 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» Psychosocial history and Development School & Activities: «» Peer relationships: «» Family relationships: «» *Body changes: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety - Seatbelts, Booster Seats: «» Violence and Firearms: «» Trampoline Safety: «» Water Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GREIG9 | Greig Health Record: Age 9 | Family history, Risk Factors, Allergies «» *Measurements Weight «» Height «» «Note: Save Encounter after entering Weight and Height and use BMI Calculator to insert BMI» Psychosocial history and Development School & Activities: «» Peer relationships: «» Family relationships: «» *Body changes: «» Menstrual issues (female only): «» *Nutrition Healthy choices / snacks / junk-food: «» Supplements / CAM: «» Body Image / Dieting: «» **Education & Advice Physical Activity: «» Electronic Media - TV / Internet / Hearing Protection: «» Sleep Issues: «» Effective Discipline: «» Helmet safety: «» Vehicle Safety - Seatbelts, Booster Seats: «» Violence and Firearms: «» Trampoline Safety: «» Water Safety: «» Sun Safety: «» Environmental Hazards - incl. Second Hand Smoke: «» Smoke Detectors: «» Other Safety Topics: «» Substance Abuse: «» Abuse: «» Dental care, fluoride: «» Specific Concerns «» Examination *** Blood Pressure «» Visual Acuity L: «» Visual Acuity R: «» CVS: «» Chest: «» Back: «» Abd: «» GU: «» *Sexual Maturity Rating: «» Skin: «» Assessment «» Update immunizations HPV (female only) Ask about chicken pox Discuss influenza vaccination Consider TB test Selected Guidelines and Resources * http://www.cps.ca/tools/GHRPage1.pdf ** http://www.cps.ca/tools/GHRPage2.pdf *** http://www.cps.ca/tools/GHRPage3.pdf «» |
| GWPREP1M | GW PrEP 1 month visit | PrEP 1-month visit - Patient in for PrEP 1 month follow-up. - No reported issues/adverse events. Tolerating medication well. - Adherence excellent: «no missed doses» - Pills remaining: «» - Bloodwork done on «date» reviewed by Dr. «»: «no issues» A/P: - As per Dr. «» Continue with Emtricitabine-tenofovir. 3 months dispensed. Lot # «». Expiry «» - Adherence reinforced, as well as importance of bone protection measures (e.g. Vitamin D) and condom use for prevention of other STIs. - Gave 3-monthly standing order lab requisition. Expires «» - Advised to call clinic when 2 weeks of medications are remaining and to go for labwork at that time. |
| GWPREP3M | GW PrEP 3 month visit | 3 monthly PrEP visit - Patient in for PrEP 3 month follow-up. - No reported issues/adverse events. Tolerating medication well. - Adherence excellent: «no missed doses» - No changes in medical hx/meds/allergies - Pills remaining: «» - Sexual hx: «» - Bloodwork done on «date» reviewed by Dr. «»: «no issues» - Last seen by Dr on «date» A/P: - As per Dr. «». Continue with Emtricitabine-tenofovir. 3 months dispensed. Lot # «». Expiry «» - Swabs for CT/GC obtained from throat and rectum - Adherence reinforced, as well as importance of bone protection measures and condom use for prevention of other STIs. - Ensured patient has a standing order at a lab. Current order valid until: «» |
| GWPREPI | GW PrEP initial visit | PrEP initial Visit Patient presents for consideration of initiation of PrEP - Allergies: «» - Medications/supplements: «» - Significant Medical Hx: «» - Copy labs to primary HCP: «» - Prior PrEP: «» - Recreational substance use: «» - HIRI-MSM Score: «» - Other risk factors: «» Prior recurrent NPEP use: «» Prior rectal STI: «» Prior syphilis: «» Known HIV+ partner where VL not <200 copies/ml: «» Sexual hx: «» Vaccinations: - HAV immune status: «» - HBV immune status: «» - HPV vaccination status: «» PrEP discussion including: - One tablet consisting of 2 antiretroviral medications, tenofovir & emtricitabine - No protection against other STIs (risk reduction counselled & condom use) - Efficacy and adherence - 7 consecutive days to reach protective levels (possibly up to 20 for vaginal sex) - Discussed reporting any seroconversion symptoms - Possible side effects on initiation: most people have none: GI, headache, dizziness, fatigue Rare: allergic rxn, renal, bone density Monitoring: baseline, Kidney fun and HIV after ~4 wks on PrEP, & every 90day Bone density: decrease, stabilizes, returns to baseline post-PrEP - Ensure best bone health with: wt-bearing exercise, calcium and vit D 1000-2000IU/day - When stopping PrEP: Continue PrEP at least 48 hours after a high risk encounter (IPERGAY protocol). Some groups recommend continuing up to 28 days. - For women: assess for pregnancy A/P: - Swabs for CT/GC obtained from throat and rectum - Lab requisition provided for PrEP baseline labwork. Will go for labwork «date range» - Dr intake appointment booked «date» |
| H208 | H208 reviewed - no f/u required | H208 reviewed. No further follow-up required |
| H208CM | H208 reviewed - Contacted client | H208 reviewed. Contacted client re: partner notification. «See Contact Management Tab»«Client has notified partners. No further follow-up required» |
| H208DIS | H208 reviewed - treatment discrepancy | H208 reviewed - treatment discrepancy noted. Called testing provider to discuss. «Client was appropriately treated. No further follow-up required» «Provider will contact client for retreatment; tasked to EPID to confirm tx» |
| H208INC | H208 Incomplete | H208 Incomplete. Called testing provider to obtain treatment info - H208 completed. |
| H208ROI | ROI Received - H208 Enetered | Client tested in ER. Treatment entered in H208 -- «as per CareConnect» «as per hospital ROI» «as per client report» Contacted client to inform Partner follow-up: «client will contact partners» «client requests Public Health assistance to contact partners -- see Contact Management Tab» |
| H208TX | H208 reviewed - treatment confirmed | H208 reviewed and treatment confirmed. |
| H219 | H219 | H219 Contact received from «» tasked to CPS EPID Priority; Hardcopy given to EPID |
| H225 | H225 | H225 Case received from «» tasked to CPS EPID Priority |
| HCCM | NS Primary Care: Client Mandate Screen (calls HCCMTEXT) | |
| HCCMTEXT | NS Primary Care: Client Mandate Screen (TEXT ONLY) | CRITERIA (must meet ALL): Not attached to Primary Care Have Complex Medical, Mental Health, and/or Substance Use Needs Require an intensive level of primary care and team based approach that cannot be provided by alternate services in the community Living in the Northshore, or if unhoused, primarily residing in the NorthShore REFERRAL TYPE: Referral type (in-person, phone, or paper): «» Referral source (if referral has been submitted on behalf of client): «» COLLATERAL INFORMATION: Gather collateral prior to meeting client as info will prompt further questions EMR (attachment to any other providers and/or last seen by previous team): «» MediNet (medications currently prescribed & name of prescriber): «» CareConnect (frequent ED visits?): «» PARIS (open to or previously attached to other teams?): «» Does client require outreach services?: «» Healthcare Attachments Does client have a primary care provider (family doctor/nurse practitioner)? «»yes/no If yes, why is client seeking access to HealthConnection Clinic? «» Other healthcare services (e.g. outreach teams, mental health & substance use teams, clinics etc.): «» Health Conditions Does client have physical, mental health, and or substance use concerns? «»yes/no Details: «» 1. «» 2. «» Psychosocial Complexity Housing Client is housed in a safe, supportive, and stable (long-term) environment? «»yes/no If no, indicate client’s housing circumstance: Details: «» Record details via (SHX94) Housing in Problem List Poverty Client has secure food, shelter, meds, predictable income and/or employment? «»yes/no If no, indicate client’s difficulty in areas of food, shelter, medication, income, and/or employment: Details: «» Record details via (SHX165) Income in Problem List Social Support Client has regular, close, and functioning social relationships among their immediate and extended social network? «»yes/no If no, indicate client’s difficulty in this area: Details: «» Record details in Problem List (various codes) Readiness to Engage Client is cooperative and willing to engage in care? «»yes/no If no, indicate client’s level of readiness? «» Hesitant/Mistrustful/Hostile Other relevant information (e.g. medical, psychosocial, risks etc.): «» DOES CLIENT MEET CRITERIA? «»yes/no AMPS Score: Record details via (SHX169) AMPS Score in Problem List If no, reason for declination: «» If Yes: Client informed of acceptance and range of services explained: «»yes/no Client informed that they may be transitioned to another primary care provider if their health and/or social situation stabilize: «»yes/no Pronouns and preferred name? (“we ask everyone; it’s okay not to answer”): «» If Pronouns provided, record details in yellow banner If No: Client informed why they do not meet criteria: «»yes/no PLAN Accepted: First visit scheduled for: «» Client care priorities: «» Declined: Client provided with alternate options: «»yes/no Referral Source Notification: Referral source notified of outcome and plan: «»yes/no |
| HCFU | Home - Follow up Consultation | PATIENT IDENTIFICATION AND MEDICAL UPDATES «» MEDICATIONS «» CURRENT ISSUES 1. «» PHYSICAL EXAMINATION PPS approximately «» . ASSESSMENT SUMMARY AND RECOMMENDATIONS In summary, «» . We reviewed your patient's illness and symptoms and have provided the following recommendations: 1. «» 2. Advanced Care Planning / Goals of Care Summary: a. BC Palliative Care Benefits Form: «» b. Code Status / Community No CPR Form: «» c. Notice of Expected Death at Home Form: «» d. SDM/contact number: «» 3. Supports: I have asked our CHN to refer the patient to occupational therapy / physiotherapy / «» for a home assessment and consideration for adaptive equipment / mobility aid / «». Our CHN will continue to reassess for opportunities to add home supports as required. 4. We have a follow-up appointment «» / we have not scheduled a follow-up appointment at this time but I am available to reassess the patient again as needed, with continuing CHN follow-up. |
| HCON | Home - Initial Consult | PATIENT IDENTIFICATION / REASON FOR CONSULTATION «» LIFE LIMITING ILLNESS «» SYMPTOM ISSUES «» OTHER MEDICAL HISTORY 1. «» MEDICATIONS «» ALLERGIES «» SOCIAL HISTORY «» GOALS OF CARE «» PHYSICAL EXAMINATION PPS approximately «» . RELEVANT INVESTIGATIONS «» ASSESSMENT SUMMARY AND RECOMMENDATIONS In summary, «» is a «» year-old with «» . The patient's recent course has been complicated by «». The patient's most significant symptoms are «», PPS «». GoC «» . Plan: 1. «» 2. Advanced Care Planning / Goals of Care Summary: a. BC Palliative Care Benefits Form: «» b. Code Status / Community No CPR Form: «» c. Notice of Expected Death at Home Form: «» d. SDM/contact number: «» 3. Supports: I have asked our CHN to refer the patient to occupational therapy / physiotherapy / «» for a home assessment and consideration for adaptive equipment / mobility aid / «». Our CHN will continue to reassess for opportunities to add home supports as required. 4. We have a follow-up appointment «» / we have not scheduled a follow-up appointment at this time but I am available to reassess the patient again as needed, with continuing CHN follow-up. |
| HCV | Open Hep C Form (HCV) | |
| HDC | Hospital Discharge Followup | |
| HDM | Injectable Hydromorphone 50mg/ml | INJECTABLE HYDROMORPHONE 50mg/ml |
| HDMI | Injectable Hydromorphone Instructions | INJECTABLE HYDROMORPHONE 1st dose: «» mg 2nd dose: «» mg 3rd dose: «» mg All doses witnessed per OAT protocol |
| HEG | Attended 2 hour Healthy Eating group class | Attended 2 hour Healthy Eating group class taught by Registered Dietitian Class content covered: · Small, frequent meals and snacks · Portions on Your Plate · Label Reading · Glycemic Index · Eating Out · Beverages · Grocery Shopping · Healthy Meal and Snack Ideas · Emotional Eating · Mindful Eating · Exercise video “23.5 hours” · Strategies to set SMART diet and exercise goals. Provided General Nutrition Recommendations: · 30 minutes exercise per day · Encourage small, frequent meals. · Increase intake of fruits, vegetables, beans, whole grains and low fat dairy products. · Reduce high fat foods, eating out and processed foods. · Limit alcohol and high sugar beverages. · Strategies to overcome emotional eating. · Healthy meal and snack ideas. · Provided individual feedback on one day food journal. · Provided healthy eating handouts, Healthy Plate placemat, resources. · Invited to use Nutrition Resources: 811 HealthLink, Bodysense 10week class, Individual nutrition consultation. Client Specific Plan/Recommendations: · «» RD: «» |
| HEPBFU | Follow-up for new Hepatitis B infections | Hepatitis B Subjective Informed client re: positive Hep B results «phone call» «clinic visit» «Symptoms:» «Asymptomatic» Known history of Hepatitis B: «yes, diagnosis date:» «no» General health/co-infections: «HIV status:» «Hep C status:» «other:» Medications: «» Sexual partners: «steady partner:» «other partners» «see STI Form: contact management» Other contacts at risk for transmission since last neg test or estimated time of infection: «household members:» «shared drug equipment: yes/no» «see STI Form: contact management» Immunization history: «Hep A» «Pneumo» «Influenza» Alcohol/substance use: «» Medical Coverage: «MSP/IFH/FNHA/None» Objective Clinical exam variances «» Mental health «» Previous serology Last negative HBsAg test: «date» «unknown» Last HIV test: «result» «date» «unknown» Anti HCV: «result» «date» «unknown» Hep A immune «yes, date:» «no» «unknown» Assessment Hepatitis B infection: «acute» «chronic» «unstaged» Plan Client education provided as per BCCDC CD Manual Hepatitis B Section - including prevention of transmission, alcohol and drug harm reduction strategies, importance of additional medical follow-up and monitoring Vaccines recommended: «Hep A» «Pneumococcal, Influenza» «advised to access through PH, primary care provider or pharmacy» Labs ordered today: «anti-HBc IgM» «Hepatitis A and Hep C» «STI/HIV screening» Referred for further assessment and ongoing Hep B care (HBV DNA, bloodwork for liver enzymes, ultrasound and/or fibroscan): «Primary care provider» «Gastoenterologist» «ID» «LAIR Centre» «other» Hep B community and online resources discussed: «Smart Sex Resource» «Canadian Liver Foundation» «CATIE» «HealthLinkBC» «Hepatitis Education Canada» Referred for harm reduction/addiction services: «yes, no, N/A» Partner Notification: «client will notify partners» «VCH CD team» Recommend Hep B vaccine for non-immune sexual and household contacts: «N/A» «client to inform contacts» «VCH CD team to follow-up» Follow Up Plan: Call client in 2wks to confirm engaged in care Repeat HBsAg in 6 months to determine chronic infection: «yes/no» |
| HEPCFU | Follow-up for new Hepatitis C infections | Hepatitis C Subjective Informed client re: positive Hep C RNA results «phone call» «clinic visit» «Symptoms:» «Asymptomatic» General health/co-infections: «HIV status:» «other:» Medications: «» Sexual partners: «steady partner:» «other partners» «see STI Form: contact management» Partners who shared injection/smoking/snorting equipment since last negative test or since estimated time of infection: «yes/no» «see STI form: contact management» Immunization history: «Hep A» «Hep B» «Pneumo» «Influenza» Alcohol/substance use: «» Medical Coverage: «MSP/IFH/FNHA/None» Objective Clinical exam variances «» Mental health «» Last negative Anti HCV or HCV RNA test:«date» «unknown» Previous serology: Hep A immune «yes, date:» «no» Hep B immune «yes, date:» «no» Last HIV test: «result» «date» «unknown» Assessment Hepatitis C infection: «acute» «active» «chronic» «unstaged» Plan Client education provided as per BCCDC CD Manual Hepatitis C Section - including prevention of transmission, alcohol and drug harm reduction strategies, free and effective treatment available. Vaccines recommended: «Hep A» «Hep B» «Pneumococcal, Influenza» «advised to access through PH, primary care provider or pharmacy» Labs ordered today: «Hepatitis A and B serology if not previously done» «STI/HIV screening» «N/A» Referred for further assessment and Hep C care (HCV genotype, bloodwork for liver enzymes, ultrasound and/or fibroscan): «Primary care provider» «Gastroenterologist» «ID» «Lair Centre» «other:» Hep C community and online resources discussed: «Help 4 Hep BC 1-888-411-7578» «Smart Sex Resource» «Canadian Liver Foundation» «CATIE» «HealthLinkBC» «Pacific Hepatitis C Network» «Hepatitis Education Canada» Referred for harm reduction/addiction services: «yes, no, N/A» Partner Notification: «client will notify partners» «VCH CD team» Follow Up Plan: Call client in 2wks to confirm engaged in care Repeat HCV RNA in 6 months to determine chronic infection: «yes/no» |
| HHEE | Attended 2 hour Healthy Heart Eating and Exercise group class | Attended 2 hour Healthy Heart Eating and Exercise group class taught by Registered Dietitian Class content covered: · What is cholesterol · Foods and Lifestyles that Raise Cholesterol · Foods and Lifestyles that Lower Cholesterol · Portions on Your Plate, Label Reading, Glycemic Index, Eating Out, Grocery Shopping. · Exercise video “23.5 hours” · 10 minute Exercise activity led by personal trainer · Strategies to set SMART diet and exercise goals. Provided General Nutrition Recommendations: · 30 minutes exercise per day · Reduce fried foods and foods high in saturated fat. Have moderate amounts of healthy fats. · Reduce processed foods high in salt and season without salt. · Increase intake of fruits, vegetables, beans, whole grains and low fat dairy products. · Include natural sources of psyllium and plant sterols. · Limit alcohol and high sugar beverages. · Encourage small, frequent meals. · Portion, salt and fat awareness when eating out. · Resources to support stress management and sufficient sleep. · Healthy meal and snack ideas. · Provided individual feedback on bloodwork. · Provided healthy heart handouts, Healthy Plate placemat, resources. · Invited to use Nutrition Resources: 811 HealthLink, Bodysense 10week class, Individual nutrition consultation. Client Specific Plan/Recommendations: · «» RD: «» |
| HICC | ICC - Interdisciplinary Care Conference | PATIENT IDENTIFICATION «» PAST MEDICAL HISTORY «» CURRENT MEDICATIONS (best possible) «» SUMMARY OF COURSE IN ACUTE CARE «» CURRENT ACUTE CARE STATUS AND COMMUNITY SUPPORT INVOLVEMENT PRIOR TO ADMISSION «» PLANNED COMMUNITY SUPPORTS TO BE ADDED ON DISCHARGE «» ADVANCED CARE PLANNING / GOALS OF CARE «» ESTIMATED DISCHARGE DATE «» ASSESSMENT SUMMARY AND RECOMMENDATIONS «» In summary, «» . We reviewed their recent admission and have provided the following recomendations to support their transition of care: 1. «» 2. Advanced Care Planning / Goals of Care Summary: a. «» b. BC Palliative Care Benefits Form: «» c. Code Status / Community No CPR Form: «» d. Notice of Expected Death at Home Form: «» e. SDM / contact number: «» FOLLOW UP «» |
| HIMJT | HIM - Davie Just Testing Appointment (calls HIMJTTEXT) | |
| HIMJTTEXT | HIM - Davie Just Testing Appointment (TEXT ONLY) | Client presented to HIM Clinic Davie for Just Testing appointment. Based on client’s responses on the “Just Testing” Intake Form, STI tests done today: HIV Syphilis Hep C Urine GC/CT Throat GC/CT Rectal GC/CT -Client aware how to obtain results |
| HIRI | HIRI-MSM Risk Index | HIRI-MSM Risk Index Calculator (Score > 10 Suggests HIV Incidence > 2% in Vancouver) Question Response Value Score 1. Age in years? 18-28 yrs ---- 8 29-40 yrs ---- 5 41-48 yrs ---- 2 ≥ 49 yrs ---- 0 «» 2. # Male partners in past 6 months? > 10 partners ---- 7 6-10 partners ---- 4 0-5 partners ---- 0 «» 3. # HIV-positive male partners in past 6 months? > 1 partner ---- 8 1 partner ---- 4 < 1 partner ---- 0 «» 4. # TIMES having unprotected receptive anal sex in past 6 months? ≥ 1 time ---- 10 0 times ---- 0 «» 5. # TIMES having unprotected insertive anal sex with an HIV (+) partner in past 6 months > 5 times ---- 6 0-4 times ---- 0 «» 6. Methamphetamine use in past 6 months? Yes ---- 5 No ---- 0 «» 7. Poppers (Nitrate Insuflation) in past 6 months? Yes ---- 3 No ---- 0 «» Total HIRI Score: «» |
| HIV | HIV Chronic Disease Management | |
| HIV2 | hiv template | hiv template syphilis |
| HIV3M | HIV Template for TBC (q3-6 months) | Subjective: • Patient Goals/Primary Concern «» • Med Review «ARVs, adherence, usual med list» • Diet «» • Harm Reduction «Sexual health, substance use, etc» • Wounds/Infections «» • Activity «» • Smoking «» • Mood «» Objective: • BW: o Last HIV Viral Load: «Letter.Patient.Macro.LATESTHIVVL» o Last CD4: «Letter.Patient.Macro.LASTCD4» o Last GFR: «Letter.Patient.Macro.LATESTGFR» o Last CBC: «Letter.Patient.Macro.LASTCBC» o Last RPR: «Letter.Patient.Macro.LATESTRPR» o Last HCV AB: «Letter.Patient.Macro.LASTHCAB» o GC and CT - «» • Wt «» • Ht «» • BP «» • PR «» • Immunizations: o HAV «» HBV «» HPV «» Td «» Pneumovax «» Prevnar «» flu «» HZV «» o TB skin test «» Assessment/Plan: 1. HIV - Check interventions, next bw due «» |
| HIVFU | HIV case follow up | HIV case follow up Subjective: Seen in clinic to «inform/follow-up» re: new HIV positive test Date of last negative HIV test: «» Symptoms: «Asymptomatic» «S/S of sero-conversion illness:» «S/S of opportunistic infections:» PMHx: General health/co-infections: «» Medications: «» Immunization history: «Hep A» «Hep B» «HPV» Sexual partners: «see STI Form: contact management» Any partners in the last 72 hours (eligible for PEP): «yes/no» Current steady partner: «yes/no» Other sexual or injection partners since time of infection/last negative HIV test: «yes/no» Medical Coverage: «MSP/IFH/FNHA/None» Other psychosocial hx: «social supports:» «housing» «» Objective: Clinical exam variances: «» Mental health: «» Previous serology: Hep A immune «yes/no/unknown», Hep B immune «yes/no/unknown» Assessment: Dx: HIV infection new case: «acute» «unstaged» «» Plan: Immediate support/safety plan:«» Client education provided as per BCCDC CD Manual - including treatment, emphasis that HIV is a manageable chronic condition; transmission prevention Vaccines given (if no previous hx): «Hep A» «Hep B» «HPV if eligible» Additional recommended vaccines: advised to discuss with HIV provider or PCP Partner Notification: «client» «BCCDC RN» «VCH PHN» Consent obtained for VCH RN to f/u with client «yes/no» Additional labs: STI testing and Hepatitis A, B, C screening (if not already done) HIV immediate staging serology (only if indicated); transported to SPH lab Link to HIV care; cc lab results to provider «Acute: refer to ID specialist, Dr. M. Hull/ Dr. S. Guillemi» «JRC» «Non-acute: refer to «JRC (IDC)» «Spectrum» «Positive Health Services» «Oak Tree» «other» » «JRC Social Worker if wrap around care needed, and/or to arrange referral if client is uninsured» Referral to Peer Navigator «accepted» «declined» Informed re: community and online resources «Crisis Line» «Positive Living BC» «AIDS Vancouver» «Smartsex Resource» «CATIE» HIV resource package given «» HIV Case Report form completed «» Follow-up plan: Client consents to 2-4 week f/u phone call by BCCDC RN «yes/no» |
| HIVPOS | HIV Positive: New Case | Notified by HIVSS of positive HIV test: «acute» «not acute» HIV Positive lab confirmed: «» Inform client to come to clinic for test results «» |
| HIVPREP | HIV PrEP Assessment | HIV PRE-EXPOSURE PROPHYLAXIS BASELINE ASSESSMENT Gender: «» M, «» F, «» F to M, «» M to F Regular GP: «» GP Name:«» Patient has spoke with GP regarding PrEP «» GP willing to prescribe PrEP«» Patient’s Current knowledge of PrEP: «» Very Knowledgeable, «» Somewhat Knowledgeable, «» Not Knowledgeable PrEP Access Date of Referral (if applicable): «» (YYYY-MM-DD) Referred from: «» Self-referred «» Community Organization «» Sexual Health Clinic «» General Practitioner «» Medical Health Officer Self-Reported Private Insurance Coverage: «» Yes, «» No, «» Unknown Coverage Approved by Private Insurance: «» Yes, «» No, «» Unknown Medical Health Officer-Approved Provincial Pilot Coverage: «» Yes, «» No, «» Unknown NIHB Coverage: «» Yes, «» No, «» Unknown Self-Funded PrEP: «» Yes, «» No, «» Unknown If Self-Funded: Online Generic Purchase? «» Yes, «» No, «» Unknown Co-Morbidities Chronic Active Hepatitis B: «» Yes, «» No, «» Unknown Hepatitis C: «» Yes, «» No, «» Unknown Chronic Renal Impairment/CKD: «» Yes, «» No, «» Unknown Diabetes: «» Yes, «» No, «» Unknown Depression: «» Yes, «» No, «» Unknown Osteoporosis: «» Yes, «» No, «» Unknown Prior Use of NPEP: «» Yes, «» No, «» Unknown Use of Erectile Dysfunction Drugs: «» Yes, «» No, «» Unknown Prior STI’s Ever Gonorrhea: «» Yes, «» No, «» Unknown Syphilis: «» Yes, «» No, «» Unknown Chlamydia: «» Yes, «» No, «» Unknown HIV Risk MSM: «» Yes, «» No, «» Unknown Known HIV+ Partner: «» Yes, «» No, «» Unknown Sex Trade Work: «» Yes, «» No, «» Unknown Injection Drug Use: «» Yes, «» No, «» Unknown Condom Use (% of use for anal/vaginal sex): With Main Partner: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% With Casual Partners: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% For Men: As Insertive Partner: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% As Receptive Partner: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% HIRI-MSM Risk Index Calculator (Score > 10 Suggests HIV Incidence > 2%) Question Response Score 1. Age in years? 18-28 yrs 8 «» 29-40 yrs 5 «» 41-48 yrs 2 «» ≥ 49 yrs 0 «» 2. # Male partners in past 6 months? > 10 partners 7 «» 6-10 partners 4 «» 0-5 partners 0 «» 3. # HIV-positive male partners in past 6 months? > 1 partner 8 «» 1 partner 4 «» < 1 partner 0 «» 4. # TIMES having unprotected receptive anal sex in past 6 months? ≥ 1 time 10 «» 0 times 0 «» 5. # TIMES having unprotected insertive anal sex with an HIV (+) partner in past 6 months ≥ 5 times 6 «» 0-4 times 0 «» 6. Methamphetamine use in past 6 months? Yes 5 «» No 0 «» 7. Poppers (Nitrate Insuflation) in past 6 months? Yes 3 «» No 0 «» Total HIRI Score: «» Substance Use in Last 6 Months Alcohol Use: «» Yes, «» No, «» Unknown CHG/Ketamine: «» Yes, «» No, «» Unknown Crystal Methamphetamine: «» Yes, «» No, «» Unknown Heroin/Opiates: «» Yes, «» No, «» Unknown Cocaine/Crack: «» Yes, «» No, «» Unknown Poppers/Amyl Nitrates: «» Yes, «» No, «» Unknown Ecstasy: «» Yes, «» No, «» Unknown Laboratory at Baseline if Available Date: << >> (YYYY-MM-DD) HGB: «» HB SAg+: «» Yes, «» No, «» Unknown WBC: «» HB SAb Titre > 10: «» Yes, «» No Neutrophils: «» HAV IgG+: «» Yes, «» No, «» Unknown Lymphocytes: «» HCV Antibody: «» Platelets: «» HIV Ab/Ag EIA: «» (NB Window Period 14 - 21 days) Creatinine: «» T. pallidum EIA: «» GFR: «» RPR Titre: «» Action PrEP Prescribed? «» Yes, «» No Date PrEP Prescribed: «» (YYYY-MM-DD) Reason for PrEP: «» Sex Trade Work, «» Prior STI, «» HIRI Score > 10 «» Prior Use of NPEP, «» Known HIV-Positive Partner «» Daily PrEP Prescribed «» On Demand PrEP Prescribed Counseling: «» Side Effects/Renal Monitoring «» Adherence «» Condoms «» HIV/STI Required q3 mo «» Weight-bearing Exercise «» Report Seroconversion Symptoms «» Vitamin D «» Follow-up in 30 Days Arranged Vaccines Dose 1 Dose 2 Dose 3 Hepatitis A «» «» «» Hepatitis B «» «» «» HPV «» «» «» Meningococcal «» |
| HIVPREP1 | HIV PrEP | HIV PRE-EXPOSURE PROPHYLAXIS BASELINE ASSESSMENT Gender: «» M, «» F, «» F to M, «» M to F Regular GP: «» GP Name:«» Patient has spoke with GP regarding PrEP «» GP willing to prescribe PrEP«» Patient’s Current knowledge of PrEP: «» Very Knowledgeable, «» Somewhat Knowledgeable, «» Not Knowledgeable PrEP Access Date of Referral (if applicable): «» (YYYY-MM-DD) Referred from: «» Self-referred «» Community Organization «» Sexual Health Clinic «» General Practitioner «» Medical Health Officer Self-Reported Private Insurance Coverage: «» Yes, «» No, «» Unknown Coverage Approved by Private Insurance: «» Yes, «» No, «» Unknown Medical Health Officer-Approved Provincial Pilot Coverage: «» Yes, «» No, «» Unknown NIHB Coverage: «» Yes, «» No, «» Unknown Self-Funded PrEP: «» Yes, «» No, «» Unknown If Self-Funded: Online Generic Purchase? «» Yes, «» No, «» Unknown Co-Morbidities Chronic Active Hepatitis B: «» Yes, «» No, «» Unknown Hepatitis C: «» Yes, «» No, «» Unknown Chronic Renal Impairment/CKD: «» Yes, «» No, «» Unknown Diabetes: «» Yes, «» No, «» Unknown Depression: «» Yes, «» No, «» Unknown Osteoporosis: «» Yes, «» No, «» Unknown Prior Use of NPEP: «» Yes, «» No, «» Unknown Use of Erectile Dysfunction Drugs: «» Yes, «» No, «» Unknown Prior STI’s Ever Gonorrhea: «» Yes, «» No, «» Unknown Syphilis: «» Yes, «» No, «» Unknown Chlamydia: «» Yes, «» No, «» Unknown HIV Risk MSM: «» Yes, «» No, «» Unknown Known HIV+ Partner: «» Yes, «» No, «» Unknown Sex Trade Work: «» Yes, «» No, «» Unknown Injection Drug Use: «» Yes, «» No, «» Unknown Condom Use (% of use for anal/vaginal sex): With Main Partner: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% With Casual Partners: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% For Men: As Insertive Partner: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% As Receptive Partner: «» Never/Seldom, «» 10-50%, «» 50-90%, «» 100% HIRI-MSM Risk Index Calculator (Score > 10 Suggests HIV Incidence > 2%) Question Response Score 1. Age in years? 18-28 yrs 8 «» 29-40 yrs 5 «» 41-48 yrs 2 «» ≥ 49 yrs 0 «» 2. # Male partners in past 6 months? > 10 partners 7 «» 6-10 partners 4 «» 0-5 partners 0 «» 3. # HIV-positive male partners in past 6 months? > 1 partner 8 «» 1 partner 4 «» < 1 partner 0 «» 4. # TIMES having unprotected receptive anal sex in past 6 months? ≥ 1 time 10 «» 0 times 0 «» 5. # TIMES having unprotected insertive anal sex with an HIV (+) partner in past 6 months ≥ 5 times 6 «» 0-4 times 0 «» 6. Methamphetamine use in past 6 months? Yes 5 «» No 0 «» 7. Poppers (Nitrate Insuflation) in past 6 months? Yes 3 «» No 0 «» Total HIRI Score: «» Substance Use in Last 6 Months Alcohol Use: «» Yes, «» No, «» Unknown CHG/Ketamine: «» Yes, «» No, «» Unknown Crystal Methamphetamine: «» Yes, «» No, «» Unknown Heroin/Opiates: «» Yes, «» No, «» Unknown Cocaine/Crack: «» Yes, «» No, «» Unknown Poppers/Amyl Nitrates: «» Yes, «» No, «» Unknown Ecstasy: «» Yes, «» No, «» Unknown Laboratory at Baseline if Available Date: «» HGB: «» HB SAg+: «» Yes, «» No, «» Unknown WBC: «» HB SAb Titre > 10: «» Yes, «» No Neutrophils: «» HAV IgG+: «» Yes, «» No, «» Unknown Lymphocytes: «» HCV Antibody: «» Platelets: «» HIV Ab/Ag EIA: «» (NB Window Period 14 - 21 days) Creatinine: «» T. pallidum EIA: «» GFR: «» RPR Titre: «» Action PrEP Prescribed? «» Yes, «» No Date PrEP Prescribed: «» Reason for PrEP: «» Sex Trade Work, «» Prior STI, «» HIRI Score > 10 «» Prior Use of NPEP, «» Known HIV-Positive Partner «» Daily PrEP Prescribed «» On Demand PrEP Prescribed Counseling: «» Side Effects/Renal Monitoring «» Adherence «» Condoms «» HIV/STI Required q3 mo «» Weight-bearing Exercise «» Report Seroconversion Symptoms «» Vitamin D «» Follow-up in 30 Days Arranged Vaccines Dose 1 Dose 2 Dose 3 Hepatitis A «» «» «» Hepatitis B «» «» «» HPV «» «» «» Meningococcal «» |
| HONOS | Health of the Nation Outcome Scale (HoNOS) - Score Sheet Adult | |
| HRNC | Hospital referral, Not Able to Contact (calls HRNCTEXT) | |
| HRNCTEXT | Hospital referral, Not Able to Contact (TEXT ONLY) | Referral Source: «HOSPITAL» Background: • Client referred to Overdose Outreach Team after presenting to «HOSPITAL» ED on «DATE» for «primary discharge reason/ctas score» • Client is NFA and unable to reach by phone • OOT was unable to provide services due to missing/incomplete contact information • If client presents please call Overdose Outreach Team at 604-360-2874 to discuss possible involvement |
| HRT1 | 1/3 HRT assessment | Name: Pronouns: Gender Journey: Goals: HRT – Surgery – ID change – Other – Social Hx: Family – Home – Work – Partner(s) - Fertility: PMHx: PSxHx: Meds: Allergies: Mental Health Hx: Substance Use Hx: FHx: |
| HRWC | Heat-Related Wellness Check (calls HRWCTEXT) | |
| HRWCTEXT | Heat-Related Wellness Check (TEXT ONLY) | Phone call or outreach visit: «» Health assessment: Reports feeling unwell or unable to cool down: «y/n» Seems slower to respond than usual: «y/n» If yes to either question, allied health professionals should refer to MRP or nurse immediately. Heat-related illness prevention: Has access to food and hydration: «yes or needs support» Has access to sunscreen and hat: «yes or needs support» Has fan or air conditioned space in building: «fan, AC, neither» Aware of nearest cooling centre: «if no, give information» Has enough medication to stay home through heat event: «if no, document in plan» Aware of how to get a hold of care team: «if no, give clinic contact info» Plan: Referred to MRP or nurse for health assessment: «» Supplies given: «food, water, sunscreen, ice packs, bandana» Ministry support for fan or AC requested or referred to SW for same: «» Medication delivery plan: «» Client transported to cooling centre or clinic: «» |
| HSG | Housing | |
| HVN | Hospital Visit Note | |
| ICOTD | ICOT Discharge (calls ICOTDTEXT) | |
| ICOTDTEXT | ICOT Discharge (TEXT ONLY) | Discharge Reason: «» Current Teams/Programs/Services/Resources: «» Location client is staying at discharge: «» Stable Housing: «yes or no (if yes, add an additional encounter title with code SHX170)» |
| ICOTI | ICOT Intake (calls ICOTITEXT) | |
| ICOTITEXT | ICOT Intake (TEXT ONLY) | Medical Hx and Current Status: Chief concerns: «» Hx of Medical Conditions: «» Hx of Mental Health: «» Family Medical Hx: «» Medication Review: Review Medinet (meds\): «» Conduct Best Possible Medication History: Allergies: «» Current meds: «» Relevant previous meds: «» Taking meds as prescribed: «» OTC meds: «» Substance Use: Current substance use (frequency, route): 1.) Opioids: «» 2.) Stimulants: «» 3.) ETOH: «» 4.) Nicotine: «» 5.) Benzodiazepines: «» 6.) Other: «» Current OAT (include dosing): «» History of substance use: «» Detox/treatment: «» Previous overdoses: «» Has THN kit/training?: «» Safer Substance Use Plan: «(may use opsp\)» Recent Labs: «» Immunization Review: «» ADLs/IADLs/Mobility: «» Social History (Add to Social/Risk Problem list): Emergency Contact and Next of Kin (Document in Client Registration Form): «» Income: «» Identified Social Work Needs: «» Where do you sleep/stay most of the time?: «» How can we best contact you?: «» |
| ICPO | Indigenous Cultural Practitioner - Outreach | |
| IDCDOD | IDC Doctor of the Day | IDC Doctor of the Day (idcdod/) (scroll through using the F4 key) Date: «RN type 'date' then '\' here» RN creator: «RN type 'sign' then '\' here» DOD: «RN type DOD name here» (RN to fill in MD names and then delete unused rows, then reassign "Holder" to DOD) AWAY 1. «MD name» - «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 2. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 3. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 4. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 5. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 6. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 7. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» OFF-SITE with EMR access 1. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 2. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 3. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 4. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 5. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 6. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» 7. «MD name»- «DOD type 'sign' then '\' here when unsigned transactions for this physician have been reviewed» (DOD - save task and reassign "Holder" to IDC Nursing group once list is completed) |
| IEN | Enteral Nutrition | Per Enteral Nutrition PPO signed by MRP, RD to initiate enteral nutrition as below: Discontinue previous EN schedule. Initiate new EN schedule below: Formula: «» Modular additions: «» Access: «» tube Method of delivery: «» system, via «» Feeding Schedule: « » for «» hours per day Amount/volume: «» mL Initial Flow Rate: «» mL/hr Goal: «» mL/hr Progression: Advance by «» mL/hr every «» hours as tolerated to goal Flushes If IV running, flush tube with «» mL water q «» h Flushes If no IV running, flush tube with «» mL water q «» h EN Provides: «» Kcal, «» g Protein, «» mL Total free water per day PO Diet provides: «» Kcal, «» g Protein, «» mL fluid per day Total nutrition provided: «» Kcal, «» g Protein, «» mL fluid per day |
| IF | Intake Form | |
| IGT1 | Prediabetes Class Day 1 | Prediabetes Class Report (Day 1) Visit Date: «Letter.Letter.Today» Attended Day 1 Prediabetes Education Class Content Reviewed: the following topics were discussed: - Pathophysiology of IFG, IGT - Diagnosis of IFG, IGT - Risk for cardiovascular disease is increased with prediabetes - Used CANRISK tool to identify risk for developing type 2 diabetes - Carbohydrate metabolism - Healthy eating for diabetes prevention using “Just the Basics” (Diabetes Canada) - Glycemic Index - Alcohol consumption - Vitamins and minerals - Healthy weight and Physical activity - Goal setting / Action planning strategies for self-care General Recommendations for All Clients Attending Diabetes Education: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes risk management 2. Blood pressure < 130/80 mmHg 3. LDL-C ≤ 2.0mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 4. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 5. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 6. Be a non-smoker Follow-Up Plan: Encouraged to continue in Day 2 of the Prediabetes Education Program Group facilitated by: RN: «» RD: «» |
| IGT2 | Prediabetes Class Day 2 | Prediabetes Class Report (Day 2) Visit Date: «Letter.Letter.Today» Attended Prediabetes Education Day 2 Class Content Reviewed: the following topics were discussed: - Goals of treatment and need for annual re-screening (A1C, ACR) - Factors that Affect Blood Sugars (illness, infection, stress, medications, etc.) - Individual lipid profiles, strategies to improve blood cholesterol levels using “Cholesterol Story” - Eating a lower sodium diet - Dietary patterns: Mediterranean, Vegetarian, DASH, Portfolio, Nordic - Weight goals - Tobacco cessation General Recommendations for All Clients Attending Diabetes Education: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes risk management 2. Blood pressure < 130/80 mmHg 3. LDL-C ≤ 2.0mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 4. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 5. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 6. Be a non-smoker Follow-Up Plan: No further follow-up planned. Information provided on health resources including Diabetes Canada and HealthLinkBC. Client invited to contact our office for diabetes education follow up appointment as needed. «» Group facilitated by: RN: «» RD: «» |
| IGTFU | Prediabetes Class Follow Up | Prediabetes Follow Up Class Report (Day 3) Visit Date: «Letter.Letter.Today» Today your patient attended Day 3 of the Managing Your Prediabetes Program, which is designed to provide an update for individuals living with prediabetes. Group Discussions: include review of: - Lab tests and target values - Pathophysiology of IFG, IGT - Guidelines for physical activity - Nutrition - Creating a healthy eating environment - Goals and strategies for menu planning - Carbohydrate recommendations - Heart Healthy Eating - Self-management goals and action planning General Recommendations for All Clients Attending Diabetes Education: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes risk management 2. Blood pressure < 130/80 mmHg 3. LDL-C ≤ 2.0mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 4. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 5. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 6. Be a non-smoker Client Specific Plan: - Client invited to schedule DEC appointment as needed Group Facilitated by: RN: «» RD: «» |
| IHMM1 | Infant health management - Month 1 | Infant Health Management - Month 1 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition Breast feeding Vit.D 10ug= 400 IU/day «discussed» Formula feeding (De Fortified) «discussed» Stool pattern & urine output «discussed» Education and Advice Carbon monoxide/smoke detectors «discussed» Non inflam. sleepwear «discussed» Hot water <54OC «discussed» Choking/safe toys «discussed» Sleep/crying «discussed» Soothability/responsiveness «discussed» Parent/chid interaction «discussed» Assess supports «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Focuses gaze «discussed» Startles to loud or sudden noise «discussed» Sucks well on nipple «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Fontanelles «discussed» Eyes (red reflex) «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Heart «discussed» Hips «discussed» Immunization Guidelines may vary by province. Give information: Immunization «discussed» Acetaminophen «discussed» If HBsAg-positive parent of sibling: Hep. B vaccine «discussed» |
| IHMM12 | Infant/Child health management - Month 12-13 | Infant/Child Health Management - Month 12-13 Growth Length «» Weight «x3 BW» Head Circumference «ave. 47cm» Parental Concerns «type parental concerns here» Nutrition Homogenized milk «discussed» Encourage cup vs bottle «discussed» Appetite reduced «discussed» Education and Advice Poisons/PCC# «discussed» Electrical plugs «discussed» Carbon monoxide/smoke detectors «discussed» Hot water , 54OC «discussed» Night waking/crying «discussed» Parent/child interaction «discussed» Teething/dental care «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Understands simple requests, e.g. find your shoes «discussed» Chatters using 3 different sounds «discussed» Crawls or bum shuffles «discussed» Pulls to stand/walks holding on «discussed» Shows many emotions «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Eyes (red reflex) «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Hips «discussed» Problems & Plans Hgb (if at risk) «discussed» Serum lend (if at risk) «discussed» Immunization Guidelines may vary by province. MMR «discussed» Varicella vaccine «discussed» |
| IHMM18 | Infant/Child health management - Month 18 | Infant/Child Health Management - Month 18 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition no bottles «discussed» Education and Advice Bath safety «discussed» Choking/safe toys «discussed» Temperament «discussed» Limit setting «discussed» Socializing opportunities «discussed» Dental care «discussed» Toilet training «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Points to pictures (eg. show me the...) «discussed» At least 5 words «discussed» Picks up and eats finger food «discussed» Walks alone «discussed» Stacks at least 3 blocks «discussed» Shows affection «discussed» Points to show parent something «discussed» Looks at you when talking/playing together «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Eyes (red reflex) «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Immunization Guidelines may vary by province. HIB «discussed» aPDT polio «discussed» |
| IHMM2 | Infant health management - Month 2 | Infant Health Management - Month 2 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition Breast feeding Vit.D 10ug= 400 IU/day «discussed» Formula feeding (De Fortified) «discussed» Education and Advice Falls «discussed» Choking/safe toys «discussed» Sleeping/crying «discussed» Soothability/responsiveness «discussed» Parent/child interaction «discussed» Depression/family stress «discussed» Fever control «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Follows movement with eyes «discussed» Has a variety of sounds & cries «discussed» Hold head up when held at adult's shoulder «discussed» Enjoys being touched & cuddled «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Fontanelles «discussed» Eyes (red reflex) «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Heart «discussed» Hips «discussed» Immunization Guidelines may vary by province. Acetaminophen «discussed» HIB «discussed» aPDT polio «discussed» |
| IHMM4 | Infant/Child health management - Month 4 | Infant/Child Health Management - Month 4 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition Breast feeding Vit.D 10ug= 400 IU/day «discussed» Formula feeding (De Fortified) «discussed» Iron fortified cereal «discussed» Education and Advice Car seat (toddler) «discussed» Stairs/walker «discussed» Bath safety/safe toys «discussed» Night waking/crying «discussed» Parent/child interaction «discussed» Child care/return to work «discussed» Teething «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Turns head towards sound «discussed» Laughs/squeals at parent «discussed» Head steady «discussed» Grasps/reaches «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Eyes (red reflex) «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Babbling «discussed» Hips «discussed» Immunization Guidelines may vary by province. HIB «discussed» aPDT polio «discussed» |
| IHMM6 | Infant/Child health management - Month 6 | Infant/Child Health Management - Month 6 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition Breast feeding Vit.D 10ug= 400 IU/day «discussed» Formula feeding. Iron fortified follow-up formula «discussed» No bottles in bed «discussed» Veg/Fruits «discussed» No egg whites, nuts or honey «discussed» Choking/safe food «discussed» Education and Advice Poisons; PCC# «discussed» Electric plugs «discussed» Night Waking/crying «discussed» Parent/child interaction «discussed» Child care/return to work «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Follows a moving object «discussed» Responds to own name «discussed» Babbles «discussed» Rolls from back to stomach or stomach to back «discussed» Sits with support «discussed» Brings hands/toys to mouth «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Fontanellles «discussed» Eyes (red reflex) «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Hips «discussed» Problems & Plans Inquire about possible TB exposure «discussed» Immunization Guidelines may vary by province. HIB «discussed» aPDT polio «discussed» if HBsAg-positive parent or sibling: Hep.B vaccine «discussed» |
| IHMM9 | Infant/Child health management - Month 9 | Infant/Child Health Management - Month 9 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition Breast feeding Vit.D 10ug= 400 IU/day «discussed» Formula feeding. Iron fortified follow-up formula «discussed» No bottles in bed «discussed» Meat and alternatives «discussed» Milk products «discussed» No egg whites, nuts or honey «discussed» Choking/safe food «discussed» Education and Advice Childproofing «discussed» Separation anxiety «discussed» Night waking/crying «discussed» Assess daycare need «discussed» Assess home visit need «discussed» Second hand smoke «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Looks for hidden toy «discussed» Babbles different sounds & to get attention «discussed» Sits without support «discussed» Stands without support «discussed» Opposes thumb & index finger «discussed» Reaches to be picked up and held «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Eyes (red reflex) «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Problems & Plans Anti-HBs & HbsAG (if BbsAg pos mother) «discussed» Hgb. (if at risk) «discussed» Immunization Guidelines may vary by province. TB skin test ? «discussed» |
| IHMW1 | Infant health management - Week 1 | Infant Health Management - Week 1 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition Breast feeding Vit.D 10ug= 400 IU/day «discussed» Formula feeding (De Fortified) [150 ml = 5ox/kg/day] «discussed» Stool pattern & urine output «discussed» Education and Advice Safety: Car seat «discussed» Crib safety «discussed» Behaviour: Sleeping/crying «discussed» Soothability/responsiveness«discussed» Family: Parenting/bonding «discussed» Fatigue/depression «discussed» Family conflict/stress «discussed» Siblings «discussed» Assess home visit needed «discussed» Sleep position «discussed» Other: Temperature control & overdressing «discussed» Second hand smoke «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Skin (jaundice, dry) «discussed» Fontanelles «discussed» Eyes (red reflex) «discussed» Ears (drums) «discussed» Heart/lungs «discussed» Umbilicus «discussed» Femoral pulses «discussed» Hips «discussed» Testicles «discussed» Male urinary stream/foreskin care «discussed» Problems and Plans PKU, Thyroid «discussed» Memoglobinopathy Screen (if at risk) «discussed» Immunization Guidelines may vary by province. If HBsAg-positive parent or sibling: Hep.B vaccine «discussed» |
| IHMW2 | Infant health management - Week 2 | Infant Health Management - Week 2 Growth Length «» Weight «» Head Circumference «» Parental Concerns «type parental concerns here» Nutrition Breast feeding Vit.D 10ug= 400 IU/day «discussed» Formula feeding (De Fortified) [150 ml = 5ox/kg/day] «discussed» Stool pattern & urine output «discussed» Education and Advice Safety: Car seat «discussed» Crib safety «discussed» Behaviour: Sleeping/crying «discussed» Soothability/responsiveness«discussed» Family: Parenting/bonding «discussed» Fatigue/depression «discussed» Family conflict/stress «discussed» Siblings «discussed» Assess home visit needed «discussed» Sleep position «discussed» Other: Temperature control & overdressing «discussed» Second hand smoke «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Skin (jaundice, dry) «discussed» Fontanelles «discussed» Eyes (red reflex) «discussed» Ears (drums) «discussed» Heart/lungs «discussed» Umbilicus «discussed» Femoral pulses «discussed» Hips «discussed» Testicles «discussed» Male urinary stream/foreskin care «discussed» |
| IHMY2 | Infant/Child health management - Year 2 | Infant/Child Health Management - Year 2 Growth Length «» Weight «» Parental Concerns «type parental concerns here» Nutrition Homogenized or 2% milk «discussed» Canada's food guide «discussed» Education and Advice Bike Helmets «discussed» Matches «discussed» Carbon monoxide/smoke detectors «discussed» Parent/child interaction «discussed» Socializing opportunities «discussed» Assess daycare and pre-school needs «discussed» Dental Care/check up «discussed» Toilet training «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. At least 1 new word/week «discussed» 2 word sentences «discussed» Tries to run «discussed» Puts objects into small container «discussed» Copies adult's actions «discussed» Continues to develop new skills «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Visual acuity «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Problems and Plans Serum lead (If at risk) «discussed» |
| IHMY3 | Infant/Child health management - Year 3 | Infant/Child Health Management - Year 3 Growth Length «» Weight «» Parental Concerns «type parental concerns here» Nutrition Homogenized or 2% milk «discussed» Canada's food guide «discussed» Education and Advice Bike Helmets «discussed» Matches «discussed» Carbon monoxide/smoke detectors «discussed» Parent/child interaction «discussed» Socializing opportunities «discussed» Assess daycare and pre-school needs «discussed» Dental Care/check up «discussed» Toilet training «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Understands 2 step direction «discussed» Twists lids off jars or turns knobs «discussed» Turns pages one at a time «discussed» Share some of the time «discussed» Listens to music or stories for 5 - 10 minutes with adults «discussed» No parent concern «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Visual acuity «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Problems and Plans Serum lead (If at risk) «discussed» |
| IHMY4 | Infant/Child health management - Year 4 | Infant/Child Health Management - Year 4 Growth Length «» Weight «» Parental Concerns «type parental concerns here» Nutrition 2% milk «discussed» Canada's food guide «discussed» Education and Advice Bike Helmets «discussed» Matches «discussed» Carbon monoxide/smoke detectors «discussed» Water safety «discussed» Socializing opportunities «discussed» Dental Care/check up «discussed» School readiness «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Understands related 3 part directions «discussed» Asks lots of questions «discussed» Stands on 1 foot for 1 to 3 seconds «discussed» Draw a person with at least 3 body parts «discussed» Toilet trained during the day «discussed» Tries to comfort someone who is upset «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Visual acuity «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Blood pressure «» Immunization MMR «discussed» aPDT polio «discussed» |
| IHMY5 | Infant/Child health management - Year 5 | Infant/Child Health Management - Year 5 Growth Length «» Weight «» Parental Concerns «type parental concerns here» Nutrition 2% milk «discussed» Canada's food guide «discussed» Education and Advice Bike Helmets «discussed» Matches «discussed» Carbon monoxide/smoke detectors «discussed» Water safety «discussed» Socializing opportunities «discussed» Dental Care/check up «discussed» School readiness «discussed» Development (inquiry & observation of milestones) Tasks are set after the time of normal milestone acquisition. Absence of any item suggests the need for further assessment of development. Counts to 10 and knows common colours & shapes «discussed» Speaks clearly in sentences «discussed» Throws and catches a ball «discussed» Hops on 1 foot «discussed» Shares willingly «discussed» Works alone on an activity for 20-30 minutes «discussed» Separates easily from parents «discussed» No parent concerns «discussed» Physical Examination Evidence based screening for specific conditions is highlighted, but an appropriate age-specific focused physical examination is recommended at each visit. Visual acuity «discussed» Cover/uncover test & inquiry «discussed» Hearing inquiry «discussed» Blood pressure «» Immunization MMR «discussed» aPDT polio «discussed» |
| IHO | title encounter as Intensive Housing Outreach Team | |
| IHOD | IHOT Discharge (calls IHODTEXT) | |
| IHODTEXT | IHOT Discharge (TEXT ONLY) | Start of Service Date: «» End of Service Date: «» Summary of Goals Met: «» Psychosocial: «» Primary Care: «» Mental Health: «» Substance Use: «» Reason for Discharge: «» Outcome/Receiving Team: «» |
| IHOI | IHOT Intake (call IHOITEXT) | |
| IHOITEXT | IHOT Intake (TEXT ONLY) | Referral Source: Background: Source of Income: Identification: Primary Care: Mental Health: Substance Use/OAT: Other Services Requested: Plan: |
| IHOTDC | Intensive Health Outreach - Discharge Form | |
| IL | RDE - Invite Letter to Client | «Letter.Letter.Today»; Invite Letter |
| ILO | Template - ILI - Office Visit - for pandemic (AccelEMR) | Influenza Like Illness - Office Visit (Sentinal Physicians - For swabs, use 'ILIL\' in Clinical Details window of Lab Req; Use billing code 'ILIS.' (for swab) and 'ILIN.' (if no swab) Subjective: (y=yes; n=no) Onset of symptoms «» days ago Symptoms: - Cough - «y» Fever - «y» Tmax «»«C or F» - SOB - «n» (if yes, put call through to doctor immediately.) Other Info - «» - Sore throat «», headache «», achiness «», vomiting «», diarrhea «» - Other symptoms - «» (* MOA - ask pt to check temp, and if age < 6, ask caretaker to check wt and inform doctor when they call back) Emergency warning signs (as per cdc.gov website): - In children - Fast breathing or trouble breathing - «n» - Bluish skin color - «n» - Not drinking enough fluids - «n» - Not waking up or not interacting - «n» - Being so irritable that the child does not want to be held - «n» - Flu-like symptoms improve but then return with fever and worse cough - «n» - Fever with a rash - «n» - In adults (>18) - Difficulty breathing or shortness of breath - «n» - Pain or pressure in the chest or abdomen - «n» - Sudden dizziness - «n» - Confusion - «n» - Severe or persistent vomiting - «n» - Green sputum - «n» Risk Factors: (if yes, consider empiric Rx for even mild sx) - Age: «n» (<5 (esp.<2) or > 65) - Medical:«n» (chronic condition of heart/lung/renal/metabolic/blood/immune system or pregnant up to 2 weeks post partum) - Vocational: «n» (Healthcare Worker, First Responder, etc) pH1N1 vaccine given? «» - if yes, within the past 2 wks? «» (likely immune by 2 weeks) Objective: Temp «» Throat «n» Chest «n» Plan: Tamiflu «n» Pharmacy «» Refer to cdc.gov website and click on "What to do if you get sick" for more information and to review warning signs and if gets, to immediately seek care. Advised to call back during office hours or call 811 after hours prn. Advised to stay home for >24 hours after fever gone without antipyretics (for healthcare workers,7 days from onset of sx and feeling better |
| IMAGEABDOMEN | Image of Abdomen |  |
| IMAGEBACK | Image of Back |  |
| IMAGEBODY | Image of Body |  |
| IMAGEBREASTS | Image of Female Breasts |  |
| IMAGECHEST | Image for Chest Examination |  |
| IMAGECLOCK | Image of Clock | «»  |
| IMAGEEAR | Image of Ear Drum |  |
| IMAGEEYES | Image of Eyes |  |
| IMAGEFEET | Image of Feet |  |
| IMAGEHEAD | Image of Head (Side View) |  |
| IMAGEHEADF | Image of Head (Front View) |  |
| IMAGELFOOT | Image of Left Foot |  |
| IMAGELHAND | Image of Left Hand |  |
| IMAGELUNGS | Image of Lungs |  |
| IMAGEPENIS | Image of Penis |  |
| IMAGERETINA | Image of Retina |  |
| IMAGERFOOT | Image of Right Foot |  |
| IMAGERHAND | Image of Right Hand |  |
| IMAGETHYROID | Image of Thyroid Area, Neck |  |
| IMAGEVULVA | Image of Vulva |  |
| IMMCON | Immunization Consent | Informed consent obtained by: «Letter.LoggedOnUser.FullName» on «Letter.Letter.Today» |
| IMZMPOX | Imvamune | Imvamune Lot# «» Expiration «» «R Arm subcutaneous» «L Arm subcutaneous» |
| IN | Intake Note | |
| INA | Inpatient Nutrition Care Plan - Initial (calls INATEXT) | |
| INATEXT | Inpatient Nutrition Care Plan – Initial (TEXT ONLY) | Admission date: «» Reason for consult/assessment: «» Informed consent: «» Food allergies: «» CURRENT ADMISSION Medical Diagnosis & Progress: «» Medical Tests and Procedures: «» Past Medical History: «» Family History: «» Social History: «» Lab Results: «» Medications: «» IV Fluids: «» FOOD AND NUTRITION HISTORY Current Diet provided: «» MRP Diet order: «» Nutrition Support: «» Food Intolerances/Restrictions: «» Nutrition Intake: «» Nutrition History: «» ANTHROPOMETRICS Height: «» cm «» actual «» estimated «» reported Current Weight: «» kg «» actual «» estimated «» reported Date of last weight: «» BMI: «» kg/m^2 Usual weight: «» kg Adjusted weight: «» kg for «» obesity «» dry weight Weight History: «» kg («»%) change over «» NUTRITION FOCUSED PHYSICAL FINDINGS Fat loss: «» Muscle loss: «» Edema/ascites: «» Contributing factors: «» cachexia «» sarcopenia Functional status: «» NUTRITION GASTROINTESTINAL/GENITOURINARY Dentition: «» Appetite: «» Nausea/vomiting: «» Bowel Function: «» Other nutrition risk factors: «» NUTRITION STATUS AND RISK Subjective Global Assessment (SGA) Rating: «» A. Well-Nourished «» B. Mild-Moderately Malnourished «» C. Severely Malnourished Nutrition risk: «» High risk «» Medium Risk «» Low Risk Patient at risk of Refeeding Syndrome? «» ESTIMATED NUTRITION REQUIREMENTS Estimated Energy requirement: «» kcal/d («» kcal/kg/d) Estimated Protein Requirement: «» g/d («» g/kg/d) Estimated Fluid Requirement: «» ml/d («» ml/kcal/d) Other requirement: «» NUTRITION DIAGNOSIS Problem: «» Etiology Related to: «» Signs/Symptoms As evidenced by: «» NUTRITION GOALS «» Prevention of refeeding syndrome «» Repletion of nutrition status «» Maintenance of nutrition status «» Provision of supportive/comfort care «» Management of nutrition related symptoms «» Improvement in well-being and quality of life NUTRITION INTERVENTIONS «» NUTRITION RECOMMENDATIONS «» DIETITIAN DISCHARGE/TRANSFER RECOMMENDATIONS «» Referral to «» outpatient dietitian «» Home Health dietitian «» sent «» planned. NUTRITION MONITORING & EVALUATION Follow up «» to monitor «». «» Follow up not required. Discharged from active nutrition care. Re-refer as needed. |
| INF | Inpatient Nutrition Care Plan – Follow Up (calls INATEXT) | |
| INFLAMMATORY | PSP-MSK - Inflammatory - A&P (AccelEMR) | Inflammatory (pain at rest, soft tissue swelling, warmth, morning stiffness > 30 min, systemic symptoms especially fatigue) - Click on Prov Ref: OA/RA Algorithm and click on Rheumatoid Arthritis for overview Assess disease activity: 1. Global Disease Activity (GDA): «»/10 Physician Assessment (0=None, 10=Very Active) What is your assessment of the patient’s current disease activity? «»/10 Patient Assessment (0=Very Well, 10=Very Poor) Considering all of the ways your arthritis has affected you, how do you feel your arthritis is today? 2. Calculate: CDAI [ «» ], or SDAI [ «» ] - Click on Prov Ref: OA/RA Algorithm and go to page 31 Disease Activity: Remission [ «» ], Low [ «» ], Moderate [ «» ], High [ «» ] Consider Differential Diagnosis - Click on Prov Ref: OA/RA Algorithm and go to pgs 32-35 for further details Consider urgent/emergent referral for: Acute monoarthritis, Giant cell arteritis, Acute Systemic Vasculitis , Acute connective tissue disease, Significant unexplained constitutional symptoms - Click on Prov Ref: OA/RA Algorithm and go to pg 37 for further details If RA, start DMARD E.A.R.L.Y. (First rule out: Osteoarthritis, Crystal arthropathy, Septic arthritis, Viral arthritis, Hepatitis B & C associated arthritis, Metabolic disorders) - Click on Prov Ref: OA/RA Algorithm and go to pgs 37-42 for further details If considering NSAID, to review risk factors, nrf«Tab using F4 then Type"\" to insert dropdown» Other: «» PLAN: Imaging: «» (Yearly of hands, feet and symptomatic joints when disease is active) Medication: Acetaminophen [ «» ], NSAID [ «» ], Other [ «» ] (Treat with DMARDs E.A.R.L.Y.) Referrals: «» (Rheum q6-12/12) Education: Email OA/RA - Chronic Pain Toolkit (14 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Self-management: Email OS/RA - Self Management file (19 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Followup: «Letter.Patient.Next Appointment.Date»«» (q1-3/12 when disease active and q3-6/12 when in remission) Other: «» |
| INFTEXT | Inpatient Nutrition Care Plan – Follow Up (TEXT ONLY) | Informed consent: «» MEDICAL PROGRESS Medical Progress: «» Medical tests and procedures: «» Lab results: «» Medications: «» IV Fluids: «» FOOD AND NUTRITION HISTORY Current Diet provided: «» MRP Diet order: «» Nutrition Support: «» Nutrition Intake: «» NUTRITION FOCUSED PHYSICAL FINDINGS «» NUTRITION GASTROINTESTINAL/GENITOURINARY Appetite: «» Nausea/vomiting: «» Bowel Function: «» Other nutrition risk factors: «» NUTRITION DIAGNOSIS Previous Nutrition Problem: «» Current Nutrition Problem: «» Etiology Related to: «» Signs/Symptoms As evidenced by: «» NUTRITION INTERVENTIONS «» NUTRITION RECOMMENDATIONS «» DIETITIAN DISCHARGE/TRANSFER RECOMMENDATIONS «» Referral to «» outpatient dietitian «» Home Health dietitian «» sent «» planned. NUTRITION MONITORING & EVALUATION Follow up «» to monitor «». «» Follow up not required. Discharged from active nutrition care. Re-refer as needed. |
| INJ | Template - Injection record (AccelEMR) | Injection: «type» «dose» «IM/SC» «location» (Given by: «initials») |
| INN | Inpatient Nutrition Note (calls INNTEXT) | |
| INNTEXT | Inpatient Nutrition Note (TEXT ONLY) | Admission date: «» Reason for consult/assessment: «» Informed consent: «» Food allergies: «» NUTRITION ASSESSMENT Monitored «». «» Patient not assessed at this time as patient only seen to «» screen for nutrition risk «» provide nutritional education «» clarify diet type «» clarify food allergies «»adjust food preferences «» assess need for oral nutrition supplements (ONS). NUTRITION DIAGNOSIS «»No nutrition diagnosis at this time. Problem: «» Etiology Related to: «» Signs/Symptoms As evidenced by: «» NUTRITION INTERVENTIONS «» Change diet to «». «» No change to the nutrition care plan. «» Updated food allergies. «» Diet education provided on «». DIETITIAN DISCHARGE/TRANSFER RECOMMENDATIONS «» Referral to «» outpatient dietitian «» Home Health dietitian «» sent «»planned. NUTRITION MONITORING & EVALUATION Follow up «» to monitor «» to complete assessment «». «» Follow up not required. Discharged from active nutrition care. Re-refer as needed. |
| INSLB | Internal Syphilis Low Blood | Syphilis low blood; Copy given to clinic physician |
| IOAT1 | VCH - iOAT Prescription Day 1 | RN supervision in iOAT program (day 1): Dose 1: Inject 20 mg IV/IM. May inject 20 mg IV/IM prn in 15-20 min Dose 2: Inject 40 mg IV/IM. May inject 20 mg IV/IM prn in 15-20 min |
| IOAT2 | VCH - iOAT Prescription Day 2 | RN supervision in iOAT program (day 2): Dose 1: Inject 60 mg IV/IM. May inject 20 mg IV/IM prn in 15-20 min Dose 2: Inject 80 mg IV/IM. May inject 20 mg IV/IM prn in 15-20 min |
| IOAT3 | VCH - iOAT Prescription Day 3 | RN supervision in iOAT program (day 3): Dose 1: Inject 100 mg IV/IM. May inject 20 mg IV/IM prn in 15-20 min Dose 2: Inject 120 mg IV/IM. Induction complete |
| IOI | iOAT dosing instructions | «» mg during AM session «» mg during PM session «» mg during Evening session All doses under observation as per OAT protocol. |
| IPN | Parenteral Nutrition | Per Parenteral Nutrition PPO signed by MRP, RD to recommend parenteral nutrition as below: Per MRP, discontinue previous PN prescription and RD to recommend new parenteral nutrition below: Parenteral Nutrition solution: «» % amino acid, «» % dextrose, «» mL lipid emulsion Rate: «» mL/hr for «» hours per day Total solution volume provided: «» L per day Additives: «» mL multivitamin solution, «» mL trace element solution Provides: «» kcal, «» g protein, «» mmol sodium, «» mmol potassium, «» mmol acetate, «» mmol chloride per day. Above recommendations signed by «» and faxed to pharmacy |
| ISI | Indigenous Self Identification | |
| ISN | Insite Note | |
| ITCB | ITC: Behaviour(calls ITCBTEXT) | |
| ITCBTEXT | ITC: Behaviour (TEXT ONLY) | Description of incident: «» Action taken: «» Reminder: «» Letter of Expectation: «» Behaviour contract: «» Recommendation for team: «» |
| ITCD | ITC: Dose Direction (calls ITCDTEXT) | |
| ITCDTEXT | ITC: Dose Direction (TEXT ONLY) | Description of situation: «» Dose Direction (must include drug, dose, route, frequency, prescriber): «» Pop up in OAT created? «Y/N» |
| ITCG | ITC: General (calls ITCGTEXT) | |
| ITCGTEXT | ITC: General (TEXT ONLY) | Subjective: «» Objective: «» Assessment / Plan: [Follow up «Letter.Patient.Next Appointment.Date»] with [«Letter.Patient.Next Appointment.ProviderName»] «» «» |
| ITCH | ITC: Dose Held (calls ITCHTEXT) | |
| ITCHTEXT | ITC: Dose Held (TEXT ONLY) | Observation: «» Assessment: «» Intervention and Plan: «» |
| ITCI | ITC: Dose Intolerance (calls ITCITEXT) | |
| ITCITEXT | ITC: Dose Intolerance (TEXT ONLY) | Observation: «» Assessment: RR «» O2sat «» BP «» PR «» Intervention and Plan: «» |
| ITCV | ITC: Vital Signs (calls ITCVTEXT) | |
| ITCVTEXT | ITC: Vital Signs (TEXT ONLY) | RR «» O2sat «» BP «» PR «» Weight «» Temp «» |
| IUC | IUC Counselling | IUC Counselling Data: • Current contraception: «» • LNMP: «» • Unprotected intercourse since LNMP: «none» • Previous pregnancy: «no» • Previous IUC: «» • STI screen: o Signs and symptoms of STI: «» o Date of last STI testing: «» o Number of partners last 2/12 : «» Action: • Pregnancy test: «negative» • STI testing: «» • Reviewed VCH IUD/IUS Pamphlet, insertion procedure handout, consent form, contraindications, and side effects • Reviewed instructions to prepare for IUC insertion • Decided on «» IUC • Rx provided by «» Plan: • Client to book IUC insertion appointment • Aware to use reliable form of contraception until IUC insertion |
| IUD | IUD | IUD Type: «» Last Menstrual Period: «» Menstrual Flow: «light»«medium»«heavy» Method used to collect menstrual fluid: «pads»«tampons»«menstrual cup» Urine hCG Pregnancy Test: «positive»«negative» Exam & IUD Insertion Uterus: «anteverted»«retroverted» Uterus sounded to (cm): «» Para-cervical block used: «yes»«no» IUD lot #: «» IUD exp #: «» IUD Removal date: «» Education & Follow up Plan Reviewed normal course of recovery (cramping, bleeding/spotting): «yes»«no» Discussed IUD self checks: «yes»«no» Patient information materials provided: «yes»«no» Advised of follow-up appointment in 4-6 weeks for IUD check: «yes»«no» Advised of s/s prompting return to clinic (significant pain, fever, flu-like symptoms, abnormal vaginal discharge): «yes»«no» Prophylaxis medications given: «yes»«no» Note «» |
| JP1 | PSP-MSK (SOAP) - Joint Pain - Initial Visit (calls JP1TEXT) | |
| JP1TEXT | PSP-MSK (SOAP) - Joint Pain - Initial Visit (TEXT ONLY) | Joint Pain - Initial Visit SUBJECTIVE: «Tab using F4» [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] A. HPI «» B. Essential Questions Location: Non-articular [ «» ], Monocarticular [ «» ], Polyarticular [ «» ] Onset: Duration over 6 weeks [ «» ] Pain: Rest [ «» ], Night [ «» ], Radiating to «» Morning Stiffness: Duratation «» min (over 30 min significant for inflammation) Functional Limits: «» Walking Tolerance: None [ «» ], House only [ «» ], Distance: < 1 block [ «» ], 1-5 blocks [ «» ], > 5 blocks [ «» ] Without significant pain Pain - avg last month: «» /10 (10=Very Severe) How much pain have you had in the last month, on average, from your joints? Pain Control: Satisfied [ «» ], Unsatisfied [ «» ] Other Info: «» C. Screening (Red Flags): Trauma [ «» ], Acute severe pain [ «» ], Neurogenic or claudication pain pattern [ «» ], Muscle weakness [ «» ] Hot and swollen joint(s) [ «» ], Night pain [ «» ], Constitutional symptoms (eg fever, weight loss, malaise) [ «» ] No red flags [ «» ] OBJECTIVE: Gait: «» Deformity: «» Inflammation: swelling [ «» ], redness [ «» ], warmth [ «» ] *If signs of inflammation, perform a joint count: # Tender [ «» ], # Swollen [ «» ] (or record on Homunculus - Go to Forms\Homunculus) Pain on movement: «» Range of motion: «» Strength; Wasting: «»/5; «» Other (balance, length): «» Labs: Last CRP: «Letter.Patient.Macro.LATESTCRP» Last RF: «Letter.Patient.Macro.LATESTRF» Last ANA: «Letter.Patient.Macro.LATESTANA» (if not previously done, order Investigation Set 'CTD') ASSESSMENT (Use F4 to move to either Non-inflammatory or Inflammatory option below Noninflammatory«Type"\" to activate drop down (Pain with activity, bone swelling, morning stiffness < 30 min) - Click on Prov Ref: OA/RA Algorithm and click on Osteoarthritis for overview» Inflammatory«Type"\" to activate drop down (Pain at rest, soft tissue swelling, warmth, morning stiffness > 30 min, systemic symptoms especially fatigue) - Click on Prov Ref: OA/RA Algorithm and click on Rheumatoid Arthritis for overview» |
| JRCIAN | JRC - Initial Assessment - Nursing | |
| JRCIASW | JRC - Initial Assessment - Social Work | |
| JRCNI | JRC Nursing Intake | JRC Nursing Intake (Press F4 to toggle through the different ) Reason for Intake to JRC: «» HIV History: «» Medical History: (Press spacebar after measurement to link to Measures table) bp «» wt «» ht «» Other Practitioners Involved in Care of Client: «» Mental Health History: «» Substance Use History: «» Psychosocial Assessment: «» Immediate Needs: «» Follow Up: Nursing Physician Pharmacy Acuity Score |
| KEXN | Template - Knee Exam - Normal (AccelEMR) | Examination of the «R/L» knee was normal including no visibly asymmetry, deformity, swelling, or muscle wasting. The gate was non-antalgic. Range of motion was full and painless. There was no palpable tenderness over the joint lines, patella, or patellar tendon. All 4 ligaments were solid with firm endpoints. There was no notable effusion. |
| KINJ | Template - Knee injection (AccelEMR) | After obtaining consent (including discussion of risks including allergy, skin atrophy, and septic arthritis), the «R or L» knee was cleaned with 3 swabs of isopropyl alcohol and injected with 40 mg of kenalog and 1 cc of xylocaine without epi from the «medial or lateral» approach using a 25 g syringe. Well tolerated. Billing Code: 56405 |
| KM | Template - Key Measures (AccelEMR) | Key Measures: BP «» Ht «» Wt «» (Recorded by: «initials») |
| KOBINSP | KOB Monthly Suite Inspections Summary (calls KOBINSP) | |
| KOBINSPTEXT | KOB Monthly Suite Inspections Summary (TEXT ONLY) | Green Zone: · FLOORS swept and mostly free of clutter · SURFACES, stovetop, counters clean and useable · FOOD items stored in refrigerator and cupboards · BATHROOM sink, toilet, tub, and surfaces clean and useable · GARBAGE and recycling are appropriately disposed of · Items and belongings ORGANIZED and put away Yellow Zone: · FLOORS not swept or mopped · SURFACES not clean, Items left on STOVETOP – potential fire or safety hazard · Multiple open FOOD containers and not stored in the refrigerator · BATHROOM sink, toilet, tub and surfaces not clean · GARBAGE and other items on the floor – but pathways are clear · Excessive CLUTTER or Items scattered throughout suite and NOT ORGANIZED or starting to accumulate more belongings without appropriate storage Red Zone · Excessive GARBAGE and items on FLOOR - no clear pathway · SURFACES excessively cluttered, including cigarette ash and butts on surfaces and counters or Cooking SURFACES and STOVE unusable · Rotten FOOD items and possible resulting insect/pest infestation, malodour · BATHROOM sink, toilet, tub, and surfaces excessively dirty, damaged, or unusable · HARM REDUCTION SUPPLIES including needles not safely discarded · FIRE and/or SAFETY hazard identified: |
| LA1C | Template - Lab: Last HgbA1c (AccelEMR) | Last HgbA1c: «Letter.Patient.Macro.LATESTA1C» |
| LACR | VCH - Last ACR | Last ACR: «Letter.Patient.Macro.LASTACR» |
| LAPOB | Last Apolipoprotein B-100 | Last ApoB-100: «Letter.Patient.Macro.LASTAPOB100» |
| LB12 | Template - Lab: Last VB12 | Last B12: «Letter.Patient.Macro.LATESTB12» |
| LBA | Repeat Syphilis Serology | Repeat syphilis serology 2 weeks after initial test AND administer Bicillin 2.4 million units IM (should be same day). «Pregnancy test recommended (patient able to get pregnant and ≤ 50 years» |
| LBP | Low Back Assessment (calls LBPTEXT) | |
| LBPRF | PSP-MSK - Low Back Pain - Red Flags (AccelEMR) | Red Flags: [ «» ] Neurological: motor or sensory loss, progressive neurological defects, cauda equina syndrome [ «» ] Infection: fever, IV drug use, immune suppressed (eg. steroid use) [ «» ] Fracture: trauma, osteoporosis risk [ «» ] Tumor: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue [ «» ] Inflammation: onset > 3 months ago, age < 45, morning stiffness > 30min, improvement with exercise, disproportionate night pain [ «» ] No red flags ToViewRedFlags |
| LBPS1 | PSP-MSK (SOAP) - Low Back Pain - Initial Visit (callsLBPS1TEXT) | |
| LBPS1TEXT | PSP-MSK (SOAP) - Low Back Pain - Initial Visit (TEXT ONLY) | Low Back Pain - Initial Visit SUBJECTIVE: «Tab using F4» [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] A. HPI «» B. Essential Questions: Where is your pain the worst? «Back Dominant» «Leg Dominant» Is your pain intermittent or constant? «Intermittent» « Constant (rule out red flags below) » Does bending forward make your typical pain worse? «Yes» «No» Has there been a change in your bladder or bowel function since your back pain started? «Yes» «No» (if Yes, rule out Cauda Equina Syndrome) (If age <45) Are you experiencing morning stiffness in back > 30min «Yes» «No» (If Yes, Systemic Inflammatory Arthritis Screen) C. Screening (Red Flags): [ «» ] Neurological: motor or sensory loss, progressive neurological defects, cauda equina syndrome [ «» ] Infection: fever, IV drug use, immune suppressed (eg. steroid use) [ «» ] Fracture: trauma, osteoporosis risk [ «» ] Tumor: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue [ «» ] Inflammation: onset > 3 months ago, age < 45, morning stiffness > 30min, improvement with exercise, disproportionate night pain [ «» ] No red flags D. Other Questions What can't you do now that you could do before? - «» What positions or movements relieve the pain? - «» When have you had this same pain before? - «» What treatment have you had before? - «» Rate the pain on a 1-10 scale - at its worst in the last week «» /10 Rate the pain on a 1-10 scale - at its least in the last week «» /10 Other Info - «» E. If No Improvement - Barriers to Recovery (Yellow flags): [ «» ] Belief that pain and activity will cause physical harm [ «» ] Problems at work, poor job satisfaction [ «» ] Excessive reliance on rest, time off work or dependency on others [ «» ] Unsupportive/dysfunctional or dependent family relationships [ «» ] Persistent low or negative moods, social withdrawal [ «» ] Over exaggeration/catastrophyzing of pain symptoms [ «» ] Belief that passive treatment (modalities) is key to recovery [ «» ] No yellow flags OBJECTIVE: Gait: Heel walking (L4-5) [ «» ] normal [ «» ] Toe walking (S1) [ «» ] Standing: Flexion provocation [ «» ] Ext provocation [ «» ] normal [ «» ] Trendelenberg test (L5) [ «» ] Repeat toe raises (S1) [ «» ] Sitting: Patellar reflex (L3-4) [ «» ] Ankle reflex (S1) [ «» ] normal [ «» ] Power: Quadriceps (L3-4) «» /5 Ankle dorsiflexion (L4-5) «» /5 Great toe ext (L4) «» /5 Great toe flexion (S1) «» /5 Plantar response (upper motor neuron test) «up (abnormal)» «down (normal)» Lying: Supine: Passive straight leg raising [ «» ] normal [ «» ] Passive hip range of movement [ «» ] Prone: Femoral nerve stretch (L3-4) [ «» ] Power: gluteus maximus «» /5 Saddle sensation (S2,3,4) [ «» ] Passive back extension [ «» ] All of above normal: [ «» ] ASSESSMENT: Mechanical: - Back Dominant Flexion Aggravated - Passive Ext Positive (PEP) [ «» ] - probably discogenic - Passive Ext Negative (PEN) [ «» ] - probably discogenic Extension Aggravated [ «» ] - possibly from the posterior elements - Leg Dominant Constant with pos nerve irritation tests [ «» ] - sciatica Intermittent - aggravated by standing/walking & relieved with flexion [«»] - neurogenic claudication Non-Mechanical: - Non-spine related pain [ «» ] - Spine pain does not fit mechanical pattern [ «» ] PLAN: Recovery Positions [ «» ] Starter Exercises [ «» ] Medication: Acetaminophen [ «» ], NSAID [ «» ], Muscle Relaxant [ «» ], Other [ «» ] Patient Info: Print: Acute Info [ «» ], Subacute Info [ «» ]; Email: Chronic Pain Toolkit (14 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Referrals [ «» ] Followup: «Letter.Patient.Next Appointment.Date»«» Other: «» |
| LBPS2 | PSP-MSK (SOAP)-Low Back Pain - Follow-up Visit(calls LBPS2TEXT) | |
| LBPS2TEXT | PSP-MSK (SOAP) - Low Back Pain - Follow-up Visit (TEXT ONLY) | Low Back Pain - Follow-up Visit SUBJECTIVE: «Tab using F4» [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] What's changed since our last visit? - «» What can't you do now that you could do before? - «» What positions or movements relieve the pain? - «» When have you had this same pain before? - «» What treatment have you had before? - «» Rate the pain on a 1-10 scale - at its worst in the last week «» /10 Rate the pain on a 1-10 scale - at its least in the last week «» /10 Other Info - «» Red Flags: ToViewRF«Tab using F4 then Type"\" to insert dropdown» Yellow Flags: (Barriers to Recovery) ToViewYF«Tab using F4 then Type"\"to insert dropdown» OBJECTIVE: Gait: Heel walking (L4-5) [ «» ] normal [ «» ] Toe walking (S1) [ «» ] Standing: Flexion provocation [ «» ] Ext provocation [ «» ] normal [ «» ] Trendelenberg test (L5) [ «» ] Repeat toe raises (S1) [ «» ] Sitting: Patellar reflex (L3-4) [ «» ] Ankle reflex (S1) [ «» ] normal [ «» ] Power: Quadriceps (L3-4) «» /5 Ankle dorsiflexion (L4-5) «» /5 Great toe ext (L4) «» /5 Great toe flexion (S1) «» /5 Plantar response (upper motor neuron test) «up (abnormal)» «down (normal)» Lying: Supine: Passive straight leg raising [ «» ] normal [ «» ] Passive hip range of movement [ «» ] Prone: Femoral nerve stretch (L3-4) [ «» ] Power: gluteus maximus «» /5 Saddle sensation (S2,3,4) [ «» ] Passive back extension [ «» ] All of above normal: [ «» ] ASSESSMENT: «» PLAN: Medication: Acetaminophen [ «» ], NSAID [ «» ], Muscle Relaxant [ «» ], Other [ «» ] Patient Info: Print: Acute Info [ «» ], Subacute Info [ «» ]; Email: Chronic Pain Toolkit (14 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Referrals [ «» ] Followup: «Letter.Patient.Next Appointment.Date»«» Other: «» |
| LBPTEXT | Low Back Assessment (TEXT ONLY) | Subjective Assessment: Chief Complaint:«» Onset:«» MOI:«» Characteristics:«» Intensity:«» Duration and Frequency:«» Aggravating Factors:«» Alleviating Factors:«» Previous Episodes:«» Red flags:«» Beliefs of what is going on:«» Pain Management:«» Mobility/Functional Tolerance Gait Aids:«» Falls Hx:«» Sitting tolerance:«» Standing tolerance:«» Walking tolerance:«» Past Medical History:«» Relevant Medical Conditions:«» Previous Surgeries or Injuries:«» Past Interventions:«» Past Imaging:«» Psychosocial Factors:«» Occupation:«» Housing:«» Supports:«» Meaningful engagements:«» Lifestyle:«» Mental Health:«» Goals of PT:«» Objective Assessment: «» Observation:«» Affect:«» Appearance: «» Posture:«» Palpation:«» Gait Analysis:«» Range of Motion (ROM):«» Lumbar Spine:«» Flexion:«» Extension: Lateral Flexion (left and right):«» Rotation (left and right):«» Hip:«» Flexion: L «» R «» Extension: L «» R «» External rotation: L «» R «» Internal rotation: L «» R «» Abduction: L «» R «» Adduction: L «» R «» Reflexes:«» Patellar Reflex (L3): L «» R «» Achilles Reflex (S1): L «» R «» Power:«» Hip flexion (L2): L «» R «» Knee extension (L3): L «» R «» Ankle dorsiflexion (L4): L «» R «» Hip abduction (L4,5): L «» R «» Great toe extension (L5): L «» R «» Ankle plantarflexion (S1): L «» R «» Knee flexion (S2): L «» R «» Sensory Testing:«» L1: L «» R «» L2: L «» R «» L3: L «» R «» L4: L «» R «» L5: L «» R «» S1: L «» R «» S2: L «» R «» Special Tests Straight Leg Raise «» Slump Test «» Faber Test «» SI jt Test «» Functional Tests: Functional/Transitional Movement Screen: «» Balance: «» 30 secs STS test: «» Rx:«» Education «» Exercise «» Activity Modification «» Assessment: «» Plan: «» |
| LBPYF | PSP-MSK - Low Back Pain - Yellow Flags (AccelEMR) | Yellow flags: (Barriers to Recovery) [ «» ] Belief that pain and activity will cause physical harm [ «» ] Problems at work, poor job satisfaction [ «» ] Excessive reliance on rest, time off work or dependency on others [ «» ] Unsupportive/dysfunctional or dependent family relationships [ «» ] Persistent low or negative moods, social withdrawal [ «» ] Over exaggeration/catastrophyzing of pain symptoms [ «» ] Belief that passive treatment (modalities) is key to recovery [ «» ] No yellow flags |
| LCD4 | Template - Lab: Last CD4 (VCH) | Last CD4:«Letter.Patient.Macro.LASTCD4» |
| LCR | Last Creatinine | Last Creatinine «Letter.Patient.Macro.LATESTCREATINNE» |
| LCRP | Template - Lab: Last CRP (AccelEMR) | Last CRP: «Letter.Patient.Macro.LATESTCRP» |
| LCTD | Template - Lab: CTD - Last CRP, RF, ANA (AccelEMR) | Last CTD Labs: CRP-«Letter.Patient.Macro.LATESTCRP»; RF-«Letter.Patient.Macro.LATESTRF»; ANA-«Letter.Patient.Macro.LATESTANA» |
| LDL | Last Drug Levels | Last Drug Levels Carbamazepine: «Letter.Patient.Macro.LATESTCARBAM» Clomipramine: «Letter.Patient.Macro.LATESTCLOMIP» Clozapine: «Letter.Patient.Macro.LATESTCLOZAP» Lithium: «Letter.Patient.Macro.LATESTLITH» Nortriptyline: «Letter.Patient.Macro.LATESTNORTR» Olanzapine: «Letter.Patient.Macro.LATESTOLANZA» Risperidone: «Letter.Patient.Macro.LATESTRISPER» Valproic acid: «Letter.Patient.Macro.LATESTVALAC» |
| LFBS | Template - Lab: Last FBS (AccelEMR) | Last FBS: «Letter.Patient.Macro.LATESTFBS» |
| LFT | Liver Function Test Results | Liver Function Tests: Last AST «Letter.Patient.Macro.LATESTAST» Last ALT «Letter.Patient.Macro.LATESTALT» Last Total Bilirubin «Letter.Patient.Macro.LATESTTOTALBILI» Last Albumin «Letter.Patient.Macro.LATESTALBUMIN» Last INR «Letter.Patient.Macro.LATESTINR» Last Platelets «Letter.Patient.Macro.LATESTPLATELETS» Last Gamma GT «Letter.Patient.Macro.LATESTGGT» |
| LGFR | Template - Lab: Last GFR (AccelEMR) | Last GFR: «Letter.Patient.Macro.LATESTGFR» |
| LGV | Lymphogranuloma Venerum | Date tested: «» Diagnosis: Lymphogranuloma venerum (LGV) HIV Status: «» HIV PrEP: «» Symptoms: «» Recommended Tx: Doxycycline 100mg PO bid for 21 days Partner f/u: All partners within 60 days should be tested and treated as a contact. Test of cure recommended 6 weeks after start of treatment. |
| LGVR | LGV Result | Result; Manually and electronically tasked to CPS SYPH Priority & CPS PHY. |
| LHBV | Last HBV DNA | Last HBV DNA: «Letter.Patient.Macro.LATESTHBVDNA» |
| LHCVRNA | Last HCV RNA | Last HCV RNA: «Letter.Patient.Macro.LASTHCVRNADATE» |
| LHD | Lighthouse- Discharge Note | |
| LHGB | Last Hemoglobin | Last Hemoglobin: «Letter.Patient.Macro.LATESTHEMOGLOB» |
| LHI | Lighthouse Intake Assessment | |
| LHIV | Template - Lab: Last HIV (VCH) | Last HIV:«Letter.Patient.Macro.LASTHIV» |
| LINR | Latest INR | Last INR: «Letter.Patient.Macro.LATESTINR» |
| LIQUID | Liquid nitrogen was applied after discussion of its effects (bl | Liquid nitrogen was applied after discussion of its effects (blistering, erythema, post-inflammatory hyper and hypopigmentation). |
| LLIP | Template - Lab: Last Lipids (AccelEMR) | Last Lipids: «Letter.Patient.Macro.LATESTLIPIDS» |
| LMM | Last Metabolic Monitoring | Last Metabolic Monitoring Lab Results Last Glucose - fasting: «Letter.Patient.Macro.LATESTFBG» Last Hemoglobin A1c: «Letter.Patient.Macro.LATESTA1C» Last Total Cholesterol: «Letter.Patient.Macro.LATESTTOTCHOLE» Last HDL Cholesterol: «Letter.Patient.Macro.LATESTHDLCHOLES» Last Non-HDL Cholesterol: «Letter.Patient.Macro.LATESTNOHDLCHOL» Last Triglycerides: «Letter.Patient.Macro.LATESTTRIGLYCER» |
| LOWBLOOD | Low blood - Syphilis | Does client have a history of Syphilis infection & treatment? If not, review low blood algorithm |
| LSUD | Latent Syphilis of Unknown Duration | Latent Syphilis of Unknown Duration |
| LTFU | Lost to follow-up (unable to reach client) | Lost to follow-up Multiple attempts to notify client re: «positive result/other» Attempts: «calls/text/email/letter» Unable to reach client |
| LTSH | Template - Lab: Last TSH | Last TSH: «Letter.Patient.Macro.LATESTTSH» |
| LUDS | Template - Lab: Last UDS (VCH) | Last UDS:«Letter.Patient.Macro.LASTUDS» |
| LVL | Template - Lab: Last Viral Load (VCH) | Last Viral Load:«Letter.Patient.Macro.LASTRNA» |
| LWBS | Left without being seen | Left without being seen |
| MAID | Medical Assistance in Dying | Medical Assistance in Dying assessment Date of request: Date eligible: Date referral received: ID provided: Witness for completing Patient Request Record 1632 (confirmed non-beneficiary in will): Medical records reviewed: MRP: Other MAiD assessor: Reason for request: Info from chart review: Current concerns/suffering: How long have they been considering MAiD? Are there any children who are likely to be affected by their death? Do they have any reservations about going ahead with MAiD (religious etc.)? PMH: Medications: Allergies: Previous reaction to anaesthetic: Social history: Coronary bypass? Heart valve replaced? Pacemaker? Surgery within previous 28 days? History of difficult venous access? On examination: Capacity to consent: Coercion? Feelings of burden? Assessment/Outcome: Is their death reasonably foreseeable? What condition is causing them the most suffering? Do they currently meet the criteria set under Bill C-7? Reviewed the track and next steps with them: Reviewed legal requirement of having capacity to consent on the day of MAiD provision, or the option of Waiver of Final Consent in future if at risk of loss of capacity (Track 1 only) Conclusion/Recommendations: Assessment record 1633 or 1634: MAiD route options discussed: Patient's preference: Oral or IV route Pt aware they can cancel request at any time Anticipated site of MAiD provision: Anticipated date of MAiD provision: Is their will in place? Funeral home arrangements? |
| MAR | MAR | Medication name: «» Administered: «n/a» Dispensed:«n/a» Quantity dispensed: «n/a» Concentration: «n/a» Dose: «» Frequency: «» Duration «n/a» Lot #: «n/a» Prescription expiration date «n/a» Route: «po» If injection: Site: «» Client instructions: «n/a» |
| MC | MHSU Medication Cutover | |
| MDAP | <>; missed dose/appt action plan | <>; missed dose/appt action plan discussed: <> |
| MDCR | MoDe: Crisis Response | |
| MDFU | MoDe: Follow Up | |
| MDT | MoDe Intake (calls MDTTEXT) | |
| MDTTEXT | MoDe Intake (TEXT ONLY) | The Mobile Crisis De-escalation (MoDe) Team provides same-day outreach response to clients living in shelters or supported housing sites in Vancouver’s inner city experiencing a mental health crisis. Clients are seen by a team made up of one mental health clinician and one care coordinator with access to an on-call physician. The team has a capacity to see clients for up to 30 days with the intention of connecting to appropriate health services. |
| MEDS | Get Medications from Pharmanet | |
| MET1 | VCH: Template (SOAP) Methadone - Medical Intake (AccelEMR) | Methadone - First Visit Subjective: Primary Substance(s) of Choice: «» Current Situation: «» Housing: «» Work/School: «» Income: «» Legal: «» Relationship: «» Counselling: «» Appetite: «» Sleep: «» subs«to record substance use/treatment history replace this with backslash \» Review of systems: H&Neck - «» Resp & CVS - «» GI/GU/STD - «» Derm & MSK - «» CNS & Psych - «» Objective: Vital Signs: Ht «», Wt «», BP «», PR «», Temp «», Mental Status «» Track marks: None [ «» ], Arms [ «» ], Legs [ «» ], Neck [ «» ], Abdomen [ «» ] Signs of recent opioid use: None [ «» ], Constricted pupils [ «» ], Drowsiness [ «» ], Slurred speech [ «» ], Unsteady gait [ «» ] Signs/symptoms of Withdrawal: None [ «» ], Arthralgia/myalgia [ «» ], Dilated pupils [ «» ], Diaphoresis [ «» ], Diarrhea [ «» ], Fever [ «» ], Goose flesh [ «» ], Lacrimation [ «» ], Rhinorrhea [ «» ] General - «» H&Neck - «» Chest - «» CVS - «» Abd - «» Derm - «» MSK - «» Neuro - «» Psych - «» MMSE [ « » ] (if applicable) swi«to record withdrawal or intoxication signs replace this with backslash \» Assessment: Substance Dependance to: «» Substance Abuse of: «» «» Plan: [ «» ] Pharmanet Check [ «» ] Contract Signed [ «» ] MMT - Print Path Requisition for: Methadone Set [ «» ] [ «» ] A & D counseling [ «» ] Detox [ «» ] Support Recovery [ «» ] Harm reduction [ «» ] 12-step program Other: «» Follow up: «Letter.Patient.Next Appointment.Date» «» |
| MET1C | VCH: Template - Methadone - Check List - Counselor (AccelEMR) | METHADONE INTAKE COUNSELLOR - Checklist As part of the initial intake process, the Methadone Intake Counsellor will inform the patient that attending Methadone Group will be mandatory as part of the Methadone Maintenance Program at Pender CHC. ACTION ITEMS (Add x when complete): [ «» ] Methadone Intake Assessment Form – Counselor and CDOI completed [ «» ] Methadone Group – Initial Treatment Plan completed and signed by counselor/ patient [ «» ] Consultation completed with MD/NP (MD/NP: «») [ «» ] Blood work and UDS initiated by MD/NP (MD/NP: «») [ «» ] ECG referral initiated by MD/NP (MD/NP: «») [ «» ] Pharmanet check by MD/NP ( MD/NP: «») [ «» ] F/UP MD visit for consideration of MMT start scheduled for: «» (Schedule F/UP MD visit for following MONDAY or WEDNESDAY preferably) [ «» ] Patient given note for “Fast Track” with F/UP appointment date and time |
| MET1M | VCH: Template - Methadone - Check List - MD (AccelEMR) | METHADONE INTAKE PHYSICIAN - Checklist ACTION ITEMS (Add x when complete): [ «» ] Methadone Intake Assessment Form - Counselor and CDOI reviewed [ «» ] Methadone Group - Initial Treatment Plan reviewed and signed by physician [ «» ] Blood work and UDS results reviewed (order βHCG - if applicable) [ «» ] ECG results reviewed [ «» ] Methadone Intake Assessment Form - Physician completed [ «» ] Methadone Treatment Agreement reviewed and signed by patient [ «» ] Provide copy of Methadone Treatment Agreement to patient (if desired) [ «» ] Provide copy of Methadone Group - Initial Treatment Plan to patient (if desired) [ «» ] PharmaNet check completed [ «» ] Methadone initiated: YES [ «» ] NO [ «» ] – if not, why? « » [ «» ] Methadone Maintenance Program - Patient Registration Form completed and faxed [ «» ] Family MD contacted |
| MET2 | VCH: Template (SOAP) Methadone - Follow Up Visit (AccelEMR) | Methadone Follow Up Visit Subjective: «» Methadone Status: Current Dose: «#» mg daily Last Ingestion: «date» Pharmanet check: [ «» ] Missed Doses: «#» DWI: Yes [ «» ] No [ «» ] Carry days if applicable: «#» Deliveries allowed: Yes [ «» ] No [ «» ] Current pharmacy: «» Substance Last Used Amount/Freq Route Other Details Heroin «» «» «» «» «Opiate» «» «» «» «» Crack Cocaine «» «» «» «» Cocaine (powder) «» «» «» «» BZD «» «» «» «» ETOH «» «» «» «» Crystal Meth «» «» «» «» «Other» «» «» «» «» Objective: Track marks: Not Reviewed [ «» ] OR; None [ «» ], Arms [ «» ], Legs [ «» ], Neck [ «» ] Counseling? «» Last UDS:«Letter.Patient.Macro.LASTUDS» Length of last Rx.? «» wk(s) «» swi«to record withdrawal or intoxication signs replace this with backslash \» Assessment/Plan: «» Length of this Rx «» wk(s) Rx expires on: «» |
| METG | VCH: Synopsis Tab - Methadone - Care Plan & Goals (AccelEMR) | Methadone Treatment Goals TREATMENT GOALS Goal Yes Comments Substance use «Reduce» «D/C» IV drug use «» «» «Reduce» «D/C» use of opiates «» «» «Reduce» «D/C» use of BZD «» «» «Reduce» «D/C» use of stimulants «» «» «Reduce» «D/C» use of alcohol «» «» Attendance at residential Detox «» «» Attendance at an outpatient treatment program «» «» Attendance at residential treatment program «» «» Attendance at a recovery house «» «» Attendance at peer support group eg.NA/CA/AA, SMART recovery «» «» Other (Specify): «» «» «» Physical Health Improve nutrition «» «» Weight gain «» «» Reduce emergency room visits «» «» Engage in primary care – eg. Pap smear, controlled HTN «» «» Engage in Hep C treatment program «» «» Engage in HIV care «» «» Other (Specify): «» «» «» Mental Health Engage in« individual», «couples» or «family» counseling «» «» Engage with a mental health team «» «» Other (Specify): «» «» «» Social Improve housing «» «» Initiate healthy new relationships «» «» Improve existing relationships «» «» Reconnect with family members «» «» Other (Specify): «» «» «» Vocational Attend «job re-training program» and/or «school» «» «» Volunteer «» «» Other (Specify): «» «» «» Additional Goals «» «» «» «» «» «» «» «» «» |
| MFT | Template - monofilament test: R foot- 4/4, L foot- 4/4 (AccelEM | monofilament test: R foot- «4»/4, L foot- «4»/4 |
| MGEN | Confirmed Mycoplasma Genitalium | Date tested: «» Diagnosis: Mycoplasma genitalium Resistance testing: «» Recommended Tx: «» Partner F/U: Consider treatment of current partners only (regardless of symptoms) to prevent reinfection of index case. Testing of partners not recommended unless symptomatic. Treat sexual partners with the same therapy as index case. Follow-up: Test of cure ONLY in cases that remain persistently symptomatic at least 3 weeks after treatment completion. |
| MH | Mental Health Note | |
| MHCEC | MHC Episodic Care | |
| MHCHR | MHC Harm Reduction | |
| MHCM | MHC Medical | |
| MHCMP | Mental Health Note – Close Monitoring Plan (call MHCMPTEXT) | |
| MHCMPTEXT | Mental Health Note – Close Monitoring Plan (TEXT ONLY) | Start Date: «» Review Date: «» Who is Involved: «» Reason for Close Monitoring: «» Goal: «» Plan: «» |
| MHCP | MHC Psychosocial | |
| MHCR | Certification, Recall and Voluntary Admission (calls MHCRTEXT) | |
| MHCRTEXT | Certification, Recall and Voluntary Admission (TEXT ONLY) | Provider/MH Team Contact: «» Phone: «» Email: «» Fax: «» Family/Chosen Support Person: «» Phone: «» Email: «» Fax: «» Is this a Mental Health Recall? «Y/N» If yes, date of last hospitalization: «» Do the renewal dates need to be reset? «Y/N» If yes, VPD file number: «» If no, mutual decision for voluntary hospitalization? «Y/N» *Presenting concern (why certification/recall now): «» Mental health diagnosis: «» Date of last hospitalization: «» Goal of hospitalization: «» *Residence/Recent Residence: «» *Current Location/Known Hangouts: «» *Home environment screen: *Are children present? «Y/N» Details: «» *Are other vulnerable people present? «Y/N» Details: «» *Are other people who might increase risk present? «Y/N» Details: «» *Are animals present? «Y/N» Details: «» Past or current bedbugs? «Y/N» Details: «» *Relevant recent medical history (e.g. heart attack, stroke, etc.): «» *Presentation when well: «» *Presentation when ill: «» *History of behaviour during past certifications/recalls: «» Medications: Current (include whether to maintain or consider a change to?) «» Tried previous: «» Depot with dose, next due date and frequency: «» *Current and Past Risk Beahviours: *Alcohol/Drug Use: «» *Violence: «» *Suicide/Homicide: «» *Other: «» Housing (include contact info if relevant): «» Any referrals pending: «» Additional helpful information for hospital (request for discharge to include referral to tertiary, request for discharge on extended leave, etc.): «» *Other relevant information to include for 911-Emergency/ECOMM (ensure to document if ECOMM did not accept communication of this information): «» Required Collateral (mark with x) [«»] Recent psychiatric consult and/or assessment [«»] All extended leave forms [«»] MAR [«»] CPIC |
| MHFN | MHSU Final Note (calls MHFNTEXT) | |
| MHFNTEXT | MHSU Final Note (TEXT ONLY) | 1. Referral reason: 2. Discharge reason: 3. Services provided (including number of appointments booked/attended, medications, psychosocial rehab, etc.): 4. Risk profile: 5. Plan/recommendations for future care: |
| MHN | Updates contact type to Mental Health Note | |
| MHN07 | Brokerage/collateral (macro only) | |
| MHP | Template - Mental Health Plan (AccelEMR) | MENTAL HEALTH PLAN Billing Code: 14043 - Reviewed EMR (Summary, Results, Documents, Encounters) - Reviewed linkages with other health care professionals (* Add HCP to Description line) - Reviewed medication issues - affordability, S.A., compliance, refills (* Add "Rx(spacebar)" to Social Problems prn) «none» - Test Scores: Beck - «»; Burns - «»; PHQ-9 - «»; GAD7 - «»; AUDIT - «»; Other - «» - Current Mood (1-10;10=normal): «»/10 - Suicide Risk: «low» - ADL's Affected (physical, mental, social, occupational): «» - Identified Barriers to achieving goals (* Add "Barrier" to Social Problems prn) «» - Current supports and strengths: «» DSM IV DIAGNOSIS: Axis 1 (Psych Dx): «» Axis 2 (Developmental/Personality Disorders): «none» Axis 3 (Physical Dx): See Problem List Axis 4 (Stressors): «none» Axis 5 (GAF) - Current: «1-100;20=hosp,30=psychotic,40=severe in multiple areas,50=severe,60=mod,70=mild» - Highest in past yr: «1-100;20=hosp,30=psychotic,40=severe in multiple areas,50=severe,60=mod,70=mild» Other Comments re Assessment: «» PLAN: - Personal Health Goal (* Add "Goal" to Social Problems prn) «» - Educational plan: «» - Medication Changes: «» - Expected Outcomes: «» - Reassessment will be in: «» - Other: «» |
| MHSU | MHSU v2 | |
| MHSUS | MH & SU Screener (MHSU) | |
| MHTA | MHT - Biopsychosocial Spiritual Assessment (calls MHTATEXT) | |
| MHTATEXT | MHT - Biopsychosocial Spiritual Assessment (TEXT ONLY) | Writer reviewed the medical record and met with the client for initial assessment (in person/by phone/virtually) to obtain the following information: Reason for referral: «» Summary of presenting issue: «» Cultural/spiritual considerations: «» Family/Social Constellation: «» Housing: «» Mental Health: «» Substance use/abuse: «» Trauma history: «» Current outpatient services: «» Medical/developmental history/cognition: «» Functional/IADLs: «» Financial: «» Legal: «» Education, employment and meaningful activity: «» Health Care Planning and Decision Making: «» Summary of Barriers to Treatment: «» Summary of Patient Strengths and Supports: «» Initial recommendations/Plan: «» |
| MHTD | MHT - Discharge Note (calls MHTDTEXT) | |
| MHTDTEXT | MHT - Discharge Note (TEXT ONLY) | Subjective: «» Objective: «» Assessment: «» Plan: «» |
| MHTI | MHT - Initial Assessment (calls MHTITEXT) | |
| MHTIC | MHT-Initial Contact | |
| MHTITEXT | MHT - Initial Assessment (TEXT ONLY) | The VCH Consent to Health Care Policy, VCH Information Privacy and Confidentiality Policy, and VCH Video Visit Guidelines were reviewed. Consent for service obtained. Subjective: «» Objective: «» Assessment: «» Plan: «» |
| MHTP | MHT - Follow-up Note (calls MHTPTEXT) | |
| MHTPTEXT | MHT - Follow-up Note (TEXT ONLY) | Subjective: «» Objective: «» Assessment: «» Plan: «» |
| MICSUB | Suboxone micro-induction | Suboxone micro-induction (7d): SL DWI for AM dose, PM dose carries: Day1 0.25mg (Approx 1/8th tab) ONCE. Day2 0.25mg BID. Day3 0.5mg BID. Day4 1mg BID. Day5 2mg BID Day6 4mg BID. Day 7 5mg BID. Total prescription 25.75mg (Twenty-five point seven five milligrams) |
| MICSUB1 | Suboxone micro-induction | Suboxone micro-induction (Wk1): SL DWI: D1 0.5mg (Approx 1/4 tab). D2 0.5mg. D3 1mg. D4 1.5mg. D5 2mg. D6 2.5mg. D7 3mg, then review. If missed dose, rpt missed dose (fax prescriber for new script). Total prescription = 11mg (Eleven milligrams) |
| MICSUB2 | Suboxone micro-induction | Suboxone micro-induction (Wk2): SL DWI once daily: D1 4mg. D2 5mg. D3 6mg. D4 7mg. D5 8mg. D6 10mg. D7 12mg, then review. If missed, rpt missed dose (fax prescriber for new script). Total prescription = 52mg (Fifty two milligrams) |
| ML1 | Template - Medicolegal Injury - initial visit (AccelEMR) | Medicolegal Injury - First Visit (Date of Injury - «date») Accident Description: The patient was «» Initial Symptoms: «» Initial Treatment: «» Current Symptoms: «» Current Limitations: «» Current Treatment: «» Relevant Past Med Hx: «» Objective: «» Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| ML2 | Template - Medicolegal Injury - follow up visit (AccelEMR) | Medicolegal Injury - Follow up Current Symptoms: «» Current Limitations: «» Current Treatment: «» Objective: «» Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| MM | Metabolic Monitoring Note | |
| MMSE | Template - MMSE Visit - MOA (AccelEMR) | MMSE - «»/30 (add score in Problem List). |
| MMSETT | Template - MMSE (AccelEMR) | Mini Mental State Examination - Folstein 1975 «Letter.Letter.Date» Use F4 buttton to move between place holders Orientation Day «» Date«» Month«» Season «» Year «» «»/5 Floor of building «» Suburb «» City «» State «» Country «» «»/5 Registration Name three objects (apple table penny) : 1 second between each word then ask patient to repeat all 3. One point each correct answer. Repeat until all 3 items are learnt but only score the first attempt. Ask patient to remember for later (Recall of the 3 items is tested later) «»/3 Attention or calculation Ether serial 7's one point for each (93,86,79,72,65) one point each stop at 5 OR «»/5 Spell "world" backwards - 1 point each correct letter Recall Recall the 3 learnt words ... one point each correct answer «»/3 Language Show patient a watch and ask what is this ... «»/1 Show patient a pen or pencil what is this ... «»/1 Follow a 3 stage command e.g. take the piece of paper with your left hand, fold in half and place on the floor «»/3 Repeat the phrase "No ifs ands or buts" «»/1 Obey the command written on the paper «»/1 (Large clear print :- please close your eyes) |
| MOB | Template - Mobile Lab (AccelEMR) | Mobile Laboratory Service Eligibility Request Use F4 buttton to move between place holders BC Biomedical Mobile Laboratory Service is intended as a service for patients who are unable to access a Patient Service Centre. Patients who meet one of the following criteria are eligible for Mobile Laboratory Service: Please select the appropriate criteria for service and fax this form along with a completed Laboratory Requisition to the appropriate Mobile Laboratory office. «»Patient is home and/or bed bound and leaving home would compromise the patient’s health. «» Patient is unwell and a trip outside the home would cause physical distress. «» Patient has a mental health problem such as agoraphobia, debilitating anxiety, or other psychiatric condition that prevents him/her from leaving home. «»Other. Please provide reason: Start Date: Next available or «» Length of Service: 1 year or «» Frequency of Service: «» Weekly «» Monthly «» PRN «» Other «» Mobile Laboratory offices: [ ] Burnaby, Coquitlam, New Westminster, Port Coquitlam, Port Moody, Vancouver - FAX: 604-939-4257 [ ] Aldergrove, Delta, For Langley, Langley, Surrey, White Rock - FAX: 604-572-0485 [ ] Agassiz, Chilliwack, Harrison, Sardis, Yarrow - FAX: 604-792-2553 [ ] Abbotsford, Clearbrook, Mission - FAX: 604-864-9316 [ ] Maple Ridge, Pitt Meadows - FAX: 604-465-2634 |
| MOVETX | Move Transaction (calls MOVETXTEXT) | |
| MOVETXTEXT | Move Transaction (TEXT ONLY) | «Name of result or document» was previously assigned to a different client in error. Moved to this correct client record. «MRP or delegate» aware. |
| MSCTG | MS Clinical Trial Referral | MS Clinical Trial Referral Name of Trial: Pt approved contact from MSCTG (Y/N)? |
| MSE | MSE Template for TBC | Subjective: • Client Goals/Primary Concern «» • Mood «» • Sleep «» • Appetite «» • Concentration «» • Energy «» • Substance use «» • Med review «adherence, side effects» • Psychosocial «counselling, groups» • Quality of life «home, food, social, work, volunteer» Objective: • Appearance and Behaviour «neat, disheveled, inappropriate, bizarre» • Speech «normal, pressured, impoverished» • Psychomotor behavior «body movement/gait/balance (rigidity, restlessness)» • Mood «euthymic, anxious, angry, depressed, euphoric, irritable» • Affect «congruent, flat, bright» • Thought Content «delusions, phobias, SI/HI, if yes – safety plan» • Thought Form « goal-directed, disorganized, slow, perseveration, loose, flight of ideas, tangential» • Perception «hallucinations, derealization, depersonalization» • Cognition «oriented to time and place» • Insight «good, fair, poor» • Judgement «good, fair, poor» Assessment/Plan: 1. MH - «» |
| MSELV | Mental Status Exam - Long Version | Mental Status Assessment APPEARANCE Age, Sex, Race «» Body Build «» Position «» Posture «» Eye contact «» Dress «» Alertness «» Grooming «» Manner «» Attentiveness to examiner «» Distinguishing features «» Prominent physical irregularity «» Emotional facial expression «» MOTOR BEHAVIOUR Retardation «» Agitation «» Unusual movements «» Gait «» Catatonia «» SPEECH Rate «» Rhythm «» Volume «» Amount «» Articulation «» Spontaneity «» MOOD/AFFECT Stability «» Range «» Appropriateness «» Intensity «» Affect «» Mood «» THOUGHT CONTENT Suicidal or homicidal ideation «» Depressive cognition «» Obsessions «» Ruminations «» Phobias «» Ideas of reference «» Paranoid ideation «» Magical ideation «» Delusions «» Overvalued ideas «» Thought broadcasting, insertion or withdrawal «» Other major themes discussed by client «» Reference: The Provincial Suicide Clinical Framework, PHSABC, Version 1.0, January 2011 |
| MSUB | Suboxone micro-induction 1w | Suboxone micro-induction (7d) - SL, DWI for AM dose, PM dose carries: Day1 0.25mg (Approx 1/8th tab) ONCE. Day2 0.25mg BID. Day3 0.5mg BID. Day4 1mg BID. Day5 2mg BID Day6 4mg BID. Day 7 12mg ONCE. Total dose for script = 27.75mg. If missed day, repeat missed day dose, fax prescriber for new script |
| MSUB10 | Suboxone micro-induction | Suboxone micro-induction (7d) - SL, DWI for AM dose, PM dose carries: Day1 0.25mg (Approx 1/8th tab) ONCE. Day2 0.25mg BID. Day3 0.5mg BID. Day4 1mg BID. Day5 2mg BID Day6 4mg BID. Day 7 10mg ONCE. Total dose for script = 25.75mg. If missed day, repeat missed day dose, fax prescriber for new script |
| MSUB5D | 5 day: Day 1: 0.5 mg BID | Suboxone SL 5 day microdosing induction: D1: 0.5 mg BID; D2: 1 mg BID; D3: 2 mg BID; D4: 4 mg BID; D5: 12 mg daily; Total dose = 27mg |
| MSUB6D | Suboxone micro-induction 6d | Suboxone micro-induction (6d) - 1st doses witnessed, 2nd carried : D1 0.25mg BID. D2 0.5mg BID. D3 1mg BID. D4 2mg BID. D5 4mg BID. D6 12mg daily. If missed, rpt missed dose (fax us for new script). Total dose for script = 27.5mg (TWENTY SEVEN POINT FIVE) |
| MSUBW1 | Suboxone micro-induction - Once daily | Suboxone micro-induction - SL Daily witnessed ingestion, all once daily: Day1 0.5mg (Approx 1/4 tab) ONCE. Day2 0.5mg. Day3 1mg. Day4 1.5mg. Day5 2mg. Day6 2.5mg. Day7 3mg, then patient f/u w provider. If missed day, repeat missed day dose (fax prescriber for new script). Total dose for script = 11mg (Eleven milligrams) |
| MSUBWK1 | Suboxone micro-induction (Week 1) | Suboxone micro-induction (Wk 1) - SL DWI once daily: D1 0.5mg (Approx 1/4 tab). D2 0.5mg. D3 1mg. D4 1.5mg. D5 2mg. D6 2.5mg. D7 3mg, then patient f/u w provider. If missed, rpt missed dose (fax prescriber for new script). Total dose for script = 11mg (Eleven milligrams) |
| MSUBWK2 | Suboxone micro-induction (Week 2) | Suboxone micro-induction (Wk 2) - SL DWI once daily: D1 4mg. D2 5mg. D3 6mg. D4 7mg. D5 8mg. D6 12mg. D7 12mg, then patient f/u w provider. If missed, rpt missed dose (fax prescriber for new script). Total dose for script = 54mg (Fifty four milligrams) |
| MVA1 | Template - MVA - initial visit (calls MVA1TEXT) | |
| MVA1TEXT | Template - MVA - initial visit (TEXT ONLY) | MVA - First Visit (Date of MVA - «date») - (also bill MSP 13075 if a non MVA related problem is addressed - document in a New Contact) Accident Description: The patient was a «?driver or passenger» of a «? vehicle type» with a headrest wearing a three point restraint device. What happened: «» Approx speed at time of impact: «» km/hr Airbag deployment: «yes» «no» Significant injuries to others: «» Damage to vehicle: approx $«»,000; «» Attended by EHS: «yes» «no»; if Yes, taken to ER Dept: «yes» «no» Initial Symptoms: «» Initial Treatment: «» Current Symptoms: «» Current Limitations: «» Current Treatment: «» Relevant Past Med Hx: «» Work: «include job title and physical requirements as relevant» Diagram of injury locations (completed by the patient) (Instructions - double click image, click on brush and then red colour --> pass mouse to patient to paint where it hurts)  |
| MVA2 | Template - MVA - follow up visit (calls MVA2TEXT) | |
| MVA2TEXT | Template - MVA - follow up visit (TEXT ONLY) | MVA - Follow up (also bill MSP 13075 if a non MVA related problem is addressed - document in a New Contact) Current Symptoms: «» Current Limitations: «» Current Treatment: «» |
| MVAS1 | Template (SOAP) - MVA - initial visit (calls MVAS1TEXT) | |
| MVAS1TEXT | Template (SOAP) - MVA - initial visit (TEXT ONLY) | MVA - First Visit (Date of MVA - «date») - (also bill MSP 13075 if a non MVA related problem is addressed - document in a New Contact) Accident Description: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] The patient was a «?driver or passenger» of a «? vehicle type» with a headrest wearing a three point restraint device. What happened: «» Approx speed at time of impact: «» km/hr Airbag deployment: «yes» «no» Significant injuries to others: «» Damage to vehicle: approx $«»,000; «» Attended by EHS: «yes» «no»; if Yes, taken to ER Dept: «yes» «no» Initial Symptoms: «» Initial Treatment: «» Current Symptoms: «» Current Limitations: «» Current Treatment: «» Relevant Past Med Hx: «» Work: «include job title and physical requirements as relevant» Diagram of injury locations (completed by the patient) (Instructions - double click image, click on brush and then red colour --> pass mouse to patient to paint where it hurts)  Objective: «» Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| MVAS2 | Template (SOAP) - MVA - followup visit (calls MVAS2TEXT) | |
| MVAS2TEXT | Template (SOAP) - MVA - followup visit (TEXT ONLY) | MVA - Follow up (also bill MSP 13075 if a non MVA related problem is addressed - document in a New Contact) Current Symptoms: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «» Current Limitations: «» Current Treatment: «» Objective: «» Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date» «» «» |
| NADU | Get next appointment date for a client and logged in user | |
| NCCON | NC - Consult | PATIENT INFORMATION / REASON FOR CONSULTATION «» LIFE-LIMITING ILLNESS «» SYMPTOM ISSUES «» EXAMINATION «» OTHER MEDICAL HISTORY «» SOCIAL HISTORY «» MEDICATIONS «» ALLERGIES «» PPS «» NO CPR «» BC PALLIATIVE CARE BENEFITS «» NOTIFICATION OF EXPECTED DEATH IN THE HOME «» ASSESSMENT / PLAN 1. Goals of Care: «» 2. Recommendations: «» 3. Follow-up: «» |
| NCFU | NC - Follow up | PATIENT INFORMATION AND UPDATES «» FUNCTIONAL STATUS (IADLs and ADLs) / COMMUNITY SUPPORTS: «» MEDICATIONS: «» ESAS SUMMARY: «» CURRENT ISSUES: 1. «» PHYSICAL EXAMINATION PPS Approximately «» ASSESSMENT SUMMARY AND RECOMMENDATIONS: In summary, «»«» . We reviewed your patient's illness and symptoms and have provided the following recommendations: 1. «» 2. Advanced Care Planning/Goals of Care Summary: a. «» b. BC Palliative Care Benefits Form: «» c. Code Status / Community No CPR Form: «» d. Notice of Expected Death at Home Form: «» e. SDM: «» FOLLOW-UP «» We have made a follow up appointment. |
| NDD | New Dawn Recovery – Discharge | |
| NDED1 | (NDE) Diabetes Education Day 1 | Diabetes Class Report (Day 1) Visit Date: «Letter.Letter.Today» Today your client attended their initial self-management education class on 'Managing Your Diabetes'. Class Content: the following topics were discussed: - Pathophysiology and management of diabetes - Risk factors, symptoms and criteria for diagnosis of diabetes - Goals of treatment - Relevant lab tests (ex. A1C, fasting blood glucose) - Home blood glucose monitoring - Carbohydrate metabolism - Healthy eating for diabetes using “Just the Basics” (Diabetes Canada) - Glycemic Index - Alcohol use - Supplement use (ex. Vitamin D, B12) - Healthy weight - Physical Activity - SMART Goal setting / Action planning strategies for self-care Planning and Recommendations: General recommendations for all clients managing their diabetes: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10 mmol/L pc meals 3. A1C ≤ 7% - measure every 3-6 months 4. Blood pressure < 130/80 mmHg 5. LDL ≤ 2.0 mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 6. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 7. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 8. Be a non-smoker Pharmacare certificate issued. No expiry date. Follow-Up Plan: Encouraged to attend remaining Diabetes Education Classes (Day 2 and Day 3). Group facilitated by: RN: «» RD: «» |
| NDED2 | (NDE) Diabetes Education Day 2 | Diabetes Class Report (Day 2) Visit Date: «Letter.Letter.Today» Today your client attended their second self-management education class on ‘Managing Your Diabetes’. Class Content: the following topics were discussed: - SMART Goal Setting - Stress Management - Hypoglycemia – signs, symptoms and treatment - Exercise for people with diabetes - Medications to treat diabetes - Driving guidelines - Carbohydrate counting using Diabetes Canada's “Beyond the Basics Meal Planning Guide”; recommendations for 45-60g carbohydrate with meals and 0-15g with snacks - Label Reading - Meal Planning Planning and Recommendations: General recommendations for all clients managing their diabetes: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10 mmol/L pc meals 3. A1C ≤ 7% - measure every 3-6 months 4. Blood pressure < 130/80 mmHg 5. LDL ≤ 2.0 mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 6. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 7. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 8. Be a non-smoker Follow-Up Plan: Encouraged to attend remaining Diabetes Education Classes (Day 3) Group facilitated by: RN: «» RD: «» |
| NDED3 | (NDE) Diabetes Education Day 3 | Diabetes Class Report (Day 3) Visit Date: «Letter.Letter.Today» Today your client attended their third and final self-management education class on ‘Managing Your Diabetes’. Class Content: the following topics were discussed: - Staying healthy with diabetes and prevention of chronic complications - ACR, Blood pressure goals - Eye and dental health - Travel, immunizations - Sick day management - Foot care - Individual lipid profiles, strategies to improve blood cholesterol levels using “Cholesterol Story” - Eating a lower sodium diet - Healthy dietary patterns (Mediterranean, Vegetarian, DASH, Portfolio, Nordic) - Healthy weight - Tobacco cessation Planning and Recommendations: General recommendations for all clients managing their diabetes: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10 mmol/L pc meals 3. A1C ≤ 7% - measure every 3-6 months 4. Blood pressure < 130/80 mmHg 5. LDL ≤ 2.0 mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 6. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 7. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 8. Be a non-smoker Follow-Up Plan: No further follow-up planned. Information provided on health resources including Diabetes Canada and HealthLinkBC. Client invited to contact our office for diabetes education follow up appointment as needed. Group facilitated by: RN: «» RD: «» |
| NDEDFU | North Shore Diabetes Education Follow Up Report | Diabetes Follow Up Class Report Visit Date: «Letter.Letter.Today» Today your client attended a diabetes education review class. Class Content: the following topics were reviewed: - Lab tests and target values - Signs and symptoms of hyperglycemia and hypoglycemia - Treatment of hypoglycemia - Home blood glucose monitoring - Benefits of self-blood glucose monitoring - Suggested glucose testing pattern - When to follow up with physician or healthcare provider - Pattern management using a journal - Benefits of physical activity - Nutrition - Creating a healthy eating environment, mindful eating - Goals and strategies for menu planning - Carbohydrate recommendations - Heart healthy eating - Medications used to manage diabetes - Staying healthy with diabetes and prevention of complications - Strategies for self-care - Sick day management guidelines Planning and Recommendations: General recommendations for all clients managing their diabetes: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10mmol/L pc meals 3. A1C ≤ 7% - measure every 3-6 months 4. Blood pressure < 130/80 mmHg 5. LDL ≤ 2.0mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 6. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 7. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 8. Be a non-smoker Follow-Up Plan: Client invited to schedule diabetes education follow up appointment as needed. Group facilitated by: RN: «» RD: «» |
| NDEFCF | Diabetes Foot Care Follow-Up | CONCERNS: 1. «» TREATMENT: 1. Nails trimmed, thinned and filed. 2. Calluses reduced. 3. Atrac-tain cream to skin. RECOMMENDATIONS: 1. «» |
| NDEFCN | Diabetic Foot Care Assessment | Diabetic Foot Care Assessment Client Foot Concerns: «» Test: Result/Date: Hgb A1C «Letter.Patient.Macro.LASTA1C» Medications: «Letter.Patient.UsualMedication» Anticoagulants: «» Diabetic: «» Antihypertensive: «» Diuretics: «» None: «» Allergies: «Letter.Patient.ActiveProblemsAdverse» «» Medical history: Diabetes: «» Cardiac: «» Vascular: «» Arthritis: «» Renal: «» Diabetic Complications : Retinopathy: «» Dental: «» Neuropathy: «» Other: «» Skin/Nail Assessment (mark with X): Right Foot Amputated «»Left Foot Amputated «» NAILS None54321None54321 «» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»Thick Ingrown Fungal Involuted/ Other«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «» SKIN PresentAbsentPresentAbsent «» «» «» «» «» «»«» «» «» «» «» «»Wounds/Ulcers Warts Thin Fragile Shiny Hair«» «» «» «» «» «»«» «» «» «» «» «» MACERATED WEB SPACE None «» 1-2 «» 3-4 «» 4-5 «»None «» 1-2 «» 3-4 «» 4-5 «» Dry «» Flaky «» Sweaty «» Reddened «» Rash «»Dry «» Flaky «» Sweaty «» Reddened «» Rash «» Odorous «» Cracked Heels «» Fissures «» Odorous «» Cracked Heels «» Fissures «» CORNS None «» Mild «» Mod «» Severe «»CORNS None «» Mild «» Mod «» Severe «» CALLUSES None «» Mild «» Mod «» Severe «»CALUSSES None «» Mild «» Mod «» Severe «» Right Foot Left Foot  SENSORY ASSESSMENT (mark with X) Right FootLeft Foot Sensation Numbness «» Burning/Tingling «» Prickly/Needles «»Sensation Numbness «» Burning/Tingling «» Prickly/Needles «» Monofilament Testing Present X , Absent «»  Sites Detected «» Monofilament Testing Present X , Absent «»  Sites Detected «» Circulatory Status – Foot/Lower Extremity Pale «» Pink «» Ruddy «» Brown «» ColourPale «» Pink «» Ruddy «» Brown «» Warm «» Cool «» Hot«» TemperatureWarm «» Cool «» Hot«» Present AbsentPresent Absent «» «»Edema«» «» «» «»Varicosities«» «» Present AbsentPulsesPresent Absent «» «»Dorsal Pedialis«» «» «» «»Posterior Pedialis«» «» Notes/ RN Concerns Tobacco use Y/N: «» Other: «» STRUCTURAL ASSESSMENT (mark with X) Arches - Medial «» «» «»High Neutral Dropped«» «» «» Arches - Transverse «» «»Present Dropped«» «» Hindfoot «» «»Valgus Varus«» «» Forefoot «» «»Pronated Supinated«» «» Bony Deformities «» «»Bunion Hallux Valgus«» «» Toes None54321None54321 «» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»Hammer Toes Mallet Toes Claw Toes Overlapping«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «»«» «» «» «» Pain – Right Foot Pain – Left Foot  FUNCTIONAL REVIEW (mark with X) Footwear Supportive «» Corrective «» Inappropriate «» Orthotics «» Ambulation Independent «» Assistance «» Aids None «» Cane «» Walker: 2W «» 4W «» Recommended «» Activity / Endurance Falls Risk «» Selfcare:IndependentAssistanceAdaptive Equipment Foot Hygiene Bathing/Showering«» «»«» «»«» «» Notes/ OT Concerns: «» PLAN/RECOMMENDATIONS Education Hygiene «» Footwear «» Diabetes «» Skincare «» Nail Care «» Treatment Sanitizer Spray «» Electric File «» Nails Trimmed/Filed «» Corns Reduced «» Callus Reduced «» Lotion «» Cuticle Oil «» Modifications Cushioned Liner «» Off Loading «» Toe Prop «» Orthotic Referral «» Shoe Referral «» INLOW’S 60-SECOND DIABETIC FOOT SCREENSCORE CategoryCriteriaRFLF Look1. Skin 2. Nails 3. Deformity 4. Footwear0=intact/healthy; 1=dry w fungi/light callus; 2=heavy callus; 3-open ulceration, hx ulcer 0=well-kept; 1=unkempt; 2=thick, damaged, or infected 0=no deformity; 2=mild deformity; 4=major deformity 0=appropriate; 1=inappropriate; 2=causing trauma «» «» «» «»«» «» «» «» Touch5. Temperature – Cold 6. Temperature – Hot 7. Range of Motion0=foot warm; 1=foot is cold 0=foot is warm; 1=foot is hot 0=full range of motion; 1=hallus limitus; 2=hallus rigidus; 3=hallux amputation «» «» «»«» «» «» Assess8. Monofilament Test 9. Sensation Questions 10. Pedal Pulses 11. Dependant Rubor 12. Erythema0=10 sites detected; 2=7-9 sites detected; 4=0-6 sites detected Are feet ever numb? Do they tingle? Do they burn? Feel like insects crawling? 0=no 1=yes 0=present; 1=absent 0=no; 1=yes 0=no; 1=yes «» «» «» «» «»«» «» «» «» «» Total Scores:«»«» SCREENING RESULTS AND RISK ASSESSMENT Inlow’s Results Interpretation Pot./Act. Patholgies & Care DeficitsParameters High ScoresPot./Act. Patholgies & Care DeficitsParameters High Scores «» Self-care deficit «» Callus formation «» Infected ulcer «» Infected nails1, 2, 4 4, 7moderate 1, 6, 12 2, 6, 12«» Peri Art Disease «» LOPS/Neuropathy «» Carcot changes5,10, 11 8, 9 3, 8, 9 RISK SCORE: Right Foot «» Left Foot «» Reassessment Recommendation: Time (Score) 1-3 months (20-25) «» 3 months (13-19) «» 6 months (7-12) «» Annual (0-6) «» Follow-up Appointment Footcare Program: RN «» OT «» Date discharged from program: «» |
| NDEFG1 | North Shore Diabetes Farsi Group | Diabetes Class Report (Farsi Group) Visit Date: «Letter.Letter.Today» Attended Farsi Diabetes Education Class (with Cultural Interpreter) Content Reviewed: the following topics were discussed: - Pathophysiology & management of diabetes - Risk factors, symptoms, criteria for diagnosis - Goals of treatment - Carbohydrate metabolism - Healthy eating for Diabetes using Canada’s Food Guide (Farsi translation) and Beyond the Basics meal planning - Alcohol consumption - Healthy weight and Physical activity - Lab Tests, Glucose Monitoring - Staying healthy with diabetes and prevention of chronic complications - Goal setting / Action planning strategies for self-care General Recommendations for All Clients Attending Diabetes Education: (per Diabetes Canada 2018 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10mmol/L pc meals 3. A1C ≤ 7% - measure every 3-6 months 4. Blood pressure < 130/80 mmHg 5. LDL-C ≤ 2.0mmol/L, non-HDL-C < 2.6 mmol/L, apo-B < 0.8 g/L 6. Follow healthy dietary pattern, 3 balanced, evenly spaced meals, low glycemic index 7. 150 minutes of moderate to vigorous aerobic activity/week and resistance exercise 2-3x/week 8. Be a non-smoker Pharmacare certificate issued. No expiry. Follow-Up Plan: Client invited to schedule DEC appointment as needed Group facilitated by: RN: «» RD: «» |
| NDEFG2 | North Shore Diabetes Farsi Group Day 2 | Diabetes Class Report (Farsi Day 2) Visit Date: «Letter.Letter.Today» Attended Day 2 Farsi Diabetes Education Class (with Cultural Interpreter) Content Reviewed: the following topics were discussed: - Target goals (CDA) - Staying healthy with diabetes - ACR, BP goals - Eye/oral health - Foot care reviewed - Frequency of lab tests - Travel, immunizations, sick time - Individual lipid profiles, strategies to improve blood cholesterol levels using “Cholesterol Story” - Sodium/ DASH diet/ Mediterranean Diet - Weight goals - Tobacco cessation - Vitamins, minerals - Eating out - Stress management General Recommendations for All Clients Attending Diabetes Education: (per CDA 2013 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10mmol/L pc meals 3. A1C = 7% - measure every 3-6 months 4. Blood pressure < 130/80 5. LDL = 2.0mmol/L; Total cholesterol/HDL ratio < 4.0 mmol/L 6. 3 balanced, evenly spaced meals, low glycemic index 7. Moderate aerobic activity – minimum of 30 mins 5x/week; include resistance min 2x/week 8. Be a non-smoker No further follow up planned at this time. Group facilitated by: RN: «» RD: «» |
| NDEIS | Insulin Start Typing Template (calls NDEISTEXT) | |
| NDEISTEXT | Insulin Start Typing Template (TEXT ONLY) | Insulin Order on File: «Y/N»: «» Assessment: «» The following topics were reviewed in clinic today: 1. Insulin action, dose timing and rationale for prescription as ordered by physician 2. Expiry date, proper care and storage of insulin 3. Injection technique, (site selection and rotation)rotation of sites, proper disposal of sharps 4. Hypoglycemia prevention/identification and treatment. Sample Dex 4 tabs provided: «Y/N» 5. Driving guideline (“5 to drive”) 6. Written instruction provided, Diabetes Canada “Getting Started with Insulin” handout reviewed and copy given to client Plan/Recommendations: «» Medications: «» Self-Monitoring of Blood Glucose: «» Client has been advised to self-titrate insulin by «» units, every «» days to target FBG «<7.0»mmol/L. If client experiences hypoglycemia overnight or in the morning, they have been advised to decrease insulin by «» units and follow up with HCP. Guideline on when to contact diabetes clinic or HCP for example: BG remain elevated or frequent hypoglycemia. Follow up: «» |
| NDF | New Dawn Recovery – Follow Up | |
| NDI | New Dawn Recovery – Intake Assessment | |
| NDV | Nursing Diabetes Visit (Primary Care) | Current concern - «» Review of Patient Goals - «» Med Review (Adherence, current meds, tolerance/effect) - «» Hypoglycemia (ask q visit) «» Review of glucometer readings «» Any changes to vision, recent pain (chest/neuropathy), non-healing wounds or infections? Allergies (must update in Medical record PRN) - «» Immunizations (must update in PARIS PRN) - «» Objective VS «» Review last A1C ( q 3 months) «» Blood Sugar PRN «» Foot Assessment (annual/ PRN) «» Diabetes - Issues and Plan Self-Management: Patient Goals «» Self monitoring of blood glucose (based on client targets) «» Blood Glucose control (a1c q 3 months) «» Blood Glucose meter accuracy (check annually) «» Nutrition «» Physical Activity «» Smoking/ Substance Use (Interest in quitting/harm reduction) «» Dental Health «» Neuropathy/Foot Examination (annual) «» Eye Exam (annual) «» |
| NEURON | Template - Screening Neurological Exam (AccelEMR) | Cranial Nerves: - facies symmetrical, PERL, extraoccular movements «N», symmetric palate raise, no dysphonia Cerebellar: - finger-nose testing- «N», Heel-shin testing- «N», Gait- «N» Romberg/Pronator drift: - normal without drift of arms Distal Strength: - symmetrically «5»/5 Light Touch: - «N» Deep Tendon Reflexes: - biceps, brachioradialis - symmetrical - Knee jerk, and ankle jerk - symmetrical Plantar Reflexes: - down going bilaterally |
| NEXC | Template - Nail wedge excision (AccelEMR) | After obtaining verbal informed consent including discussion of the possibilities of reaction to local anesthetic, infection, and the higher probabilities of nail regrowth and/or deformity, the «Left or Right» great toe was prepped as usual using Baxedin. About 3 cc of 2% xylocaine was then used to inject a ring block around the toe. After achieving adequate analgesia, anvil nippers were used to longitudinally spit the «medial or lateral» edge of the nail to the nail fold - this wedge was then grasped firmly and removed completely including the portion of the lunula. NAOH on a cotton swab was placed against the nail bed for one minute and then neutralized by 3 applications of acetic acid cotton swabs. The wound was dressed with Bacitracin and dry gauze. Post-op care handout given. (13633) |
| NN | Nursing Note | |
| NND | Syphilis No New Diagnosis | As per BCCDC Guide to Interpreting Syphilis Lab Test Results |
| NNDL | No New Diagnosis - Syphilis | No New Diagnosis as per BCCDC Guide to Interpreting Syphilis Lab Test Results. Lab sent to physician for letter recommendation. |
| NONINFLAMMATORY | PSP-MSK - Non-inflammatory - A&P (AccelEMR) | Non-inflammatory (pain with activity, bone swelling, morning stiffness < 30 min) - Click on Prov Ref: OA/RA Algorithm and click on Osteoarthritis for overview Risk Factors or OA: Obesity [ «» ], Inactivity [ «» ], Family Hx [ «» ], Muscle weakness [ «» ], Previous trauma [ «» ], Mechanical factors [ «» ], Heavy ue [ «» ], Reduced proprioception [ «» ], None [ «» ] Consider Surgery: Inadequate pain control, Increasing need for narcotic medications, Significant rest or night pain, Inability to walk without significant pain, Threat to patient’s ability to work or live independently, Progressing deformity, Decreasing range of motion, Progression of Disease on X-ray For symptomatic OA, prescribe full dose acetaminophen (1 g 4 x day) If considering NSAID, to review risk factors, nrf«Tab using F4 then Type"\" to insert dropdown» Other: «» PLAN: Medication: Acetaminophen [ «» ], NSAID [ «» ], Other [ «» ] Referrals: «» Education: Email OA/RA - Chronic Pain Toolkit (14 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Self-management: Email OS/RA - Self Management file (19 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Wt loss/diet plan: «» Joint Protection/Devices:«» Exercise program «» Followup: «Letter.Patient.Next Appointment.Date»«» (q1-3/12 when disease active and q3-6/12 when in remission) Other: «» |
| NPO | Nurse Practitioner: Outreach | |
| NPV | Nurse Practitioner: Visit | |
| NRF | PSP-MSK - NSAID Risk Factors (AccelEMR) | Risk Factors for treatment with NSAID's: CVS - HTN [ «» ], IHD [ «» ], CHF [ «» ] GI - Hx of PUD or GERD [ «» ], Smoker [ «» ], Heavy alcohol use [ «» ], Liver disease [ «» ] Renal - GFR < 60 (Last GFR: «Letter.Patient.Macro.LATESTGFR») [ «» ], Interstitial cystitis [ «» ] Meds - Diuretic [ «» ], Glucocorticoids [ «» ], Anticoagulant [ «» ] |
| NSBA | No show for booked appointment | No show for booked appointment Notes: «» Follow-up plan: «» |
| NUR | Nurse to review | Nurse to review - «Letter.Letter.Today» |
| NURS18 | Nursing: Medication Administration/Dispensing (macro only) | |
| NURS43 | Nursing Safe Supply | |
| NURSO | Nursing: Outreach | |
| NVC | Template - Non Visit Care (AccelEMR) | Non Visit Care: re CCP(14039), MHP(14049), Pall Care(14069), COPD(14073) Initiated by - «» Re - «» |
| NYD | Syphilis Physician to Nurse re NYD | Syphilis NYD. Tasked to CPS SYPH NYD |
| OA2 | PSP-MSK (SOAP) - OA - Followup Visit (calls OA2TEXT) | |
| OA2TEXT | PSP-MSK (SOAP) - OA - Followup Visit (TEXT ONLY) | Osteoarthritis - Follow-up Visit SUBJECTIVE: «Tab using F4» [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] Overall improvment: Better [ «» ], The same [ «» ], Worse[ «» ] Pain - avg last month: «» /10 (10=Very Severe) How much pain have you had in the last month, on average, from your arthritis? Pain Control: Satisfied [ «» ], Unsatisfied [ «» ] Frequency: «» Interferance with sleep: «» Morning Stiffness: Duratation «» min (over 30 min significant for inflammation) Fatigue: «» /10 (10=Very Severe) Functional Limitations: Mobility: «»; Self Care: «» Walking Tolerance: None [ «» ], House only [ «» ], Distance: < 1 block [ «» ], 1-5 blocks [ «» ], > 5 blocks [ «» ] Without significant pain Difficulties: Work: «»; Leisure: «»; Other: «» Global Disease Activity: «»/10 (0=Very Well, 10=Very Poor) Considering all of the ways your arthritis has affected you, how do you feel your arthritis is today? Medication - use/toxicity:«» Other Info: «» OBJECTIVE: Gait: «» Deformity/Alignment: «» Pain on movement: «» Range of motion: «» Strength; Wasting: «»/5; «» Other (balance, length): «» ASSESSMENT: Risk Factors or OA: Obesity [ «» ], Inactivity [ «» ], Family Hx [ «» ], Muscle weakness [ «» ], Previous trauma [ «» ], Mechanical factors [ «» ], Heavy ue [ «» ], Reduced proprioception [ «» ], None [ «» ] For symptomatic OA: Prescribe full dose acetaminophen (1 g 4 x day) If considering NSAID: To review risk factors, nrf«Tab using F4 then Type"\" to insert dropdown» Consider surgery if: Symptoms inadequately controlled; Increasing functional restrictions; Significant abnormal findings on examination; Progression of disease on X-ray. For further details, Type "ORI \" below: «» PLAN: Medication: Acetaminophen [ «» ], NSAID [ «» ], Other [ «» ] Referrals: «» Education: Email OA/RA - Chronic Pain Toolkit (14 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Self-management: Email OS/RA - Self Management file (19 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Wt loss/diet plan: «» Joint Protection/Devices:«» Exercise program «» Followup: «Letter.Patient.Next Appointment.Date»«» (q1-3/12 when disease active and q3-6/12 when in remission) Other: «» |
| OAT | OAT - see attached forms and | Opioid agonist therapy - see attached forms and details below. |
| OATF | OAT Follow up - Stepping Stones | OAT Follow up Telephone call due to Covid-19 protocol. Client assessed by writer and Dr. Ali Pharmanet checked: «» Substance Use: Type: «» Route: «» Frequency: «» Last use: «» Amount: «» Cravings: «» Withdrawal: «» Intoxication: «» MSE: «» Harm Reduction: «» Recent ODs: «» Pharmacy: «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").FullName» «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").AddressStreet» Phone: «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").Phone1» Fax: «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").Fax» Plan: «» |
| OCPTT | Template - OCP (AccelEMR) | No Hx clots, cancers, abnormal bleeding, MI, CVA, HT, liver probs, migraines, nonsmoker |
| ODIH | Outreach Doula - Indigenous Health | |
| OMD | VCH-OAT Missed Dose Date | |
| OND | Onsite – Discharge Note | |
| ONI | Onsite – Intake Assessment | |
| ONIH | Outreach Nurse – Indigenous Health | |
| ONN | Onsite - Nursing Note | Current OAT dose: «» Withdrawal Symptoms: «» Sleep: «» Food and Fluid Intake: «» PRNs Administered: «» Plan of Care/Dispo: «» |
| OOT | OOT Mandate Screening (calls OOTTEXT) | |
| OOTAN | OOT Admin Note | |
| OOTCA | OOT Client Contact Attempt | |
| OOTCAF | Overdose Outreach Client Acuity | |
| OOTCC | OOT Care Coordination | |
| OOTCCON | OOT Case Conference | |
| OOTCIN | OOT Client Instruction Note | |
| OOTCM | OOT Client Contact Made | |
| OOTCR | OOT Chart Review | |
| OOTCS | Referral declined as client is receiving care from «Care Team». Please call 604-360-2874 with any questions or to discuss referral decision. | |
| OOTDN | OOT Discharge Note (calls OOTDNTEXT) | |
| OOTDNTEXT | OOT Discharge Note (TEXT ONLY) | Client has been discharged from the Overdose Outreach Team. Please contact 604-360-2874 with any questions. |
| OOTF | Overdose Outreach Team Form | |
| OOTIDN | OOT Interaction - Client Closed to OOT (calls OOTIDNTEXT) | |
| OOTIDNTEXT | OOT Interaction - Client Closed to OOT (TEXT ONLY) | Subjective: «» Objective: «» Assessment / Plan: [Follow up ] with [ ] «» Client does not have an open referral or care plan with the Overdose Outreach Team. Please contact 604-360-2874 with any questions. |
| OOTIN | Unable to locate sufficient contact information for follow up in community. If client presents and is interested in outreach support, please call 604-360-2874. Client does not have an open referral or care plan with the Overdose Outreach Team. | |
| OOTMS | OOT Mandate Screening | |
| OOTNE | Referral received through automated report from Emergency Department. Does not meet mandate as ED presentation was not in context of accessing toxic drug supply. Client does not have an open referral or care plan with the Overdose Outreach Team. Please call 604-360-2874 with any questions. | |
| OOTONE | OOT Service Request - One Off Task (calls OOTONETEXT) | |
| OOTONETEXT | OOT Service Request - One Off Task (TEXT ONLY) | Referral Source: «» Background: «» Reason for referral: «» Risk Screen and Safety Alerts: «» Summary of Service Provided: «» This is a one off service request. Client does not have an open referral or care plan with the Overdose Outreach Team. Please contact 604-360-2874 with any questions. |
| OOTPAT | Pharmaceutical Alternative Team Intake (calls OOTPATTEXT) | |
| OOTPATTEXT | Pharmaceutical Alternative Team Intake (TEXT ONLY) | OAT preference and Hx of OAT treatment: «» Previous engagement with Pharm Alternative programs: «» Max dose achieved: «» Previous adherence to clinics/programs in the past: «» |
| OOTPSE | OOT Peer Support Engagement | |
| OOTPSU | Perinatal Substance Use Pod Intake (calls OOTPSUTEXT) | |
| OOTPSUTEXT | Perinatal Substance Use Pod Intake (TEXT ONLY) | Birthing Person or Partner: «» Pregnant or Post-Partum: «» Substance Use Hx: «» Connected to Providers: «» Connections/Supports in Community (Including family/friends) «» Partner Involvement: «» Domestic Violence or other Safety Consideration including Safety Plan: «» Stage of Readiness/Parenting Plan: «» Housing Plans Post-Birth: «» Financial: «» |
| OOTRN | OOT Nurse Prescribing (calls OOTRNTEXT) | |
| OOTRNI | OOT Nurse Prescribing – Initial Assessment (calls OOTRNITEXT) | |
| OOTRNITEXT | OOT Nurse Prescribing – Initial Assessment (TEXT ONLY) | History of Present Illness/Reason for Referral: «» Goals: «» Substance Use History: Opioids: Type: «» First use: «» Pattern: «» Benzo/Tranq Dope Seeking/Unintentional: «» Hydromorphone (unregulated or prescribed): «» Pattern of use: «» OAT Hx: «» Longest period of stability: «» Withdrawal symptoms: «» Benzodiazepines: Type: «» First use: «» Pattern: «» Contaminated dope: «» Seizure history: «» Stimulants: Type: «» First use: «» Pattern: «» Drug induced psychosis history: «» ETOH: First use: «» Pattern: «» Type: «» Non-bev: «» Seizure history: «» Hallucinogens: Type: «» First use: «» Pattern: «» GHB/Ketamine/Other Type: «» First use: «» Pattern: «» Cannabis: First use: «» Pattern: «» Nicotine: First use: «» Pattern: «» Harm Reduction: Access to clean supplies: «» OPS/using with others: «» ODs: «» Lifeguard app: «» Has naloxone: «» Drug checking: «» HR teaching: «» Pharmanet/CareConnect/Cerner review: Missed doses: «» Last ECG/QTc: «» Hx wd/complicated wd/wd hospitalizations: «» Current medical conditions (stable/unstable): «» Psych history (stable/unstable): «» Suicidal ideation/homicidal ideation: «» Hx recent hospitalizations: «» Medrec notes: «» Substance Use Treatment history: Previously received SU tx (Y/N): «» Tx hx relevant to current goals/health: «» Referral support needed: «» Social History: Housing/Shelter: «» Current supports/Primary Care: «» Pharmacy: «» Med Coverage: «» Income Source: «» |
| OOTRNO | OOT Nurse Prescribing Assessment (calls OOTRNOTEXT) | |
| OOTRNOTEXT | OOT Nurse Prescribing Assessment (TEXT ONLY) | Substance Use: «» Opioids: Type: «» Benzo/Tranq dope seeking/unintentional: «» Hydromorphone (unregulated or prescribed): «» Withdrawal symptoms: «» Benzodiazepines: Type: «» Contaminated dope: «» Seizure history: «» Stimulants: Type: «» Drug induced psychosis history: «» ETOH: Type: «» Non-bev: «» Seizure history: «» Hallucinogens: Type: «» First use: «» Pattern: «» GHB/Ketamine/Other Type: «» Pattern: «» Cannabis: Pattern: «» Nicotine: Pattern: «» Harm Reduction: Access to clean supplies: «» OPS/using with others: «» ODs: «» Lifeguard app: «» Has naloxone: «» Drug checking: «» HR teaching: «» Pharmanet/CareConnect/Cerner review: Missed doses: «» Last ECG/QTc: «» |
| OOTRNTEXT | OOT Nurse Prescribing (TEXT ONLY) | OOT Nurses provide short term prescribing. Client does not have an open referral or care plan with the Overdose Outreach Team. Please contact 604-360-2874 with any questions. |
| OOTSUS | Substance Use Stabilization Pod Intake (calls OOTSUSTEXT) | |
| OOTSUSTEXT | Substance Use Stabilization Pod Intake (TEXT ONLY) | Detox and Treatment Hx: «» Open Referrals/Waitlist for Treatment Programs: «» Preference in Treatment Programs (Outpatient, 12 Step, etc.): «» Financial/Funding for Treatment: «» Mental Health Hx: «» Medication and OAT: «» Legal: «» Stage of Change: «» |
| OOTTEXT | OOT Mandate Screening (TEXT ONLY) | Referral Source: «» Background: «» Substance Use: «» Housing/Hangouts: «» Primary Care/OAT: «» Source of Income: «» Safety/Hazard/Risk: «» Other Care Providers: «» Plan and Follow-Up: «» |
| OOTTFR | OOT Pod Transfer Note (calls OOTTFRTEXT) | |
| OOTTFRTEXT | OOT Pod Transfer Note (TEXT ONLY) | Client care is being transferred from «POD» to «POD» as of «date». Reason: «» Plan: ⦁ «» |
| OPAP | Outreach PAP | Tasked to CPS Outreach PAP; RN initial: «» |
| OPOS | Outreach Positive | Tasked to CPS Outreach POS; RN initial: «» |
| OPSP | Overdose Prevention Safety Planning | Overdose Prevention Safety Planning, OPSP\ Conduct chart review in advance to assess for overdose risk (recent incarceration, hospital/detox discharge, substance use, homelessness, concurrent mental health condition) Overdose Risk Screen ● Are you currently using any substances including alcohol, or on OAT and/or safe supply? (if yes, describe) «Y/N» ● If you use substances, how have you been keeping yourself safe? (Re-inforce client strengths)? «» ● Have you had an overdose or had naloxone used on you in the past 30 days? «Y/N» If at risk, offer supports (not limited to, remove what you don’t offer): ● Regular scheduled check ins via phone or in person ● Naloxone training ● Harm reduction education ● Strategies to Keep Safe When Using Alone (eg. Lifeguard app, Take-home drug testing, Review safer use with friends under COVID) ● Assess building staff availability to check in when using ● OAT prescription and planning (including tablet injectable opioid agonist treatment (tiOAT) and injectable opioid agonist treatment (iOAT) ● Pandemic withdrawal management ● Detox support or referral ● Overdose Outreach Team referral ● Use of supervised consumption site or overdose prevention site (provide location map) Offer longer term support based on clients goals including but not limited to: ● Social connection ● Safer housing ● Pain management ● Referrals to psychosocial programs (e.g. groups, counselling) ● Referral to treatment (inpatient or outpatient) Plan: (Add next steps regarding client safety plan) ● Document Safer Use Care Plan (shx code: “SUCP” in problem list) ● Add Intervention named ‘Safer Use Care Plan’ to revisit clients safety plan in one month with the client or more frequently if needed |
| ORCA | OAT Clinic Day Assessment (calls ORCATEXT) | |
| ORCATEXT | OAT Clinic Day Assessment (TEXT ONLY) | SUBJECTIVE: «» CURRENT USE: (Route and quantity if known) Fentanyl: «» Crystal Meth: «» Crack/Cocaine: «» Cannabis: «» Tobacco: «» ETOH: «» Other: «» Using Alone? «» Narcan: «» Recent OD’s?: «» OBJECTIVE: «» ASSESSMENTS: «» UDS Result today + for; Physical Health: «» Mental Health: «» PLAN: «» |
| ORCI | OAT Clinic Intake Assessment (calls ORCITEXT) | |
| ORCITEXT | OAT Clinic Intake Assessment (TEXT ONLY) | SECHELT OAT CLINIC INTAKE ASSESSMENT Presenting Reason: «» Transfer of Service? : «» GENERAL INFORMATION Housing: «» Income source: «» Support Team history: «» Pharmacy: «» OAT HISTORY (Latest Rx) OAT: MMT- «» Kadian- «» Suboxone- «» Sublocade- «» Detox/Treatment Hx: «» Longest period without substances / medication and dose at that time: «» SUBSTANCE USE HISTORY Fentanyl: «» Benzos: «» Crystal Meth: «» Crack/Cocaine: «» THC: «» ETOH: «» Tobacco: «» Other: «» Overdose History: «» Has a Narcan Kit: «» PHYSICAL HEALTH Allergies: «» Past/Present issues/Surgeries: «» Current Meds – (highest previous dose if known): «» Medical- «» OAT- «» Supplementary- «» MENTAL HEALTH Past/present issues/previous follow up: «» IN CLINIC ASSESSMENT Todays UDS Result: «» OBJECTIVE:«» Goals: «» Referrals required: «» Harm Reduction Conversation done: Y/N: «» PLAN: «» |
| ORCN | OAT Pre-Clinic Note (calls ORCNTEXT) | |
| ORCNTEXT | OAT Pre-Clinic Note (TEXT ONLY) | Recent Developments/follow up from previous Dr notes: «» MEDICATIONS ( Rx duration and recent changes): «» OAT Meds: «» Supplementary Meds: «» Missed doses: «» MOST RECENT ENGAGEMENT: «» In person with Dr: «» Telehealth with Dr: «» In person with Nurse: «» Last UDS result (Date): «» Recent Care Connect encounters: «» PARIS information if applicable: «» |
| ORCS | OOT Referral, Connected to Services (calls ORCSTEXT) | |
| ORCSI | OAT Clinic Sublocade Injection (calls ORCSITEXT) | |
| ORCSITEXT | OAT Clinic Sublocade Injection (TEXT ONLY) | Subjective: «» Objective: «» Rapid UDT Result - + for: «» ACTION: «» Next Injection Due (Date and Site): «» Task Completed in EMR and New Task Created: «» Renewal Appointment created in EMR for Dr to write rx 2 weeks before next due date: «» |
| ORCSTEXT | OOT Referral, Connected to Services (TEXT ONLY) | Referral Source: «» Background: Client was referred to the Overdose Outreach Team after presenting to «Hospital» on «DATE» for «CTAS SCORE» Client is currently engaged in care with «» and was last seen «» OOT informed most responsible care provider of recent substance related event No role for the Overdose Outreach Team at this time If client disengages from care, please contact the Overdose Outreach Team at 604-360-2874 to discuss possible re-referral |
| ORECALL | Encounter Note after Reopening of Closed Recall Task | Closed recall plan was reopened. |
| OREFER | Outreach Contact Info | IMPORTANT: Please contact BCCDC CPS Outreach with appointment information. Phone: 604-707-2790, Fax: 604-707-2794 |
| ORI | PSP-MSK - OA - Referral Indications (AccelEMR) | Osteoarthritis Referral Indications: Symptoms Inadequately Controlled [ «» ] Inadequate pain control [ «» ] Increasing need for narcotic medications [ «» ] Significant pain on motion, resting pain, presence of night pain Increasing Functional Restrictions [ «» ] Inability to walk without significant pain [ «» ] Significantly modified daily activities (e.g. putting on shoes, climbing stairs, squatting and bending) [ «» ] Increasing threat to patient’s ability to work or live independently Significant Abnormal findings on Examination [ «» ] Progressing deformity [ «» ] Loss of extension [ «» ] Loss of flexion [ «» ] Decreasing range of motion. [ «» ] Notable leg length discrepancy Progression of Disease on X-ray [ «» ] Evidence of progressive bone loss [ «» ] Advanced loss of joint space in association with moderate to severe pain [ «» ] In the hip, evidence of increasing acetabular protrusion or femoral head collapse |
| ORTB | ORT - Bridging Rx | |
| ORTEW | ORT - Emergency Withdrawal | |
| ORTI | ORT - Intake | |
| ORTO | ORT - Ongoing | |
| OSN | Onsite Note | |
| OT | Occupational Therapist Note | |
| OTA | OT MHSU Assessment | |
| OTFH | OT Functional Housing Assessment | |
| OTO | Occupational Therapist Outreach Note | |
| OUD | Opioid Use Disorder | |
| OUDFU | Opiod Use Disorder Follow Up | Opioid Use Disorder Follow Up Visit Subjective: «» Opioid Substance Use Status: Suboxone «» Methadone «» Current Dose: «#» mg daily Last Ingestion: «date» Pharmanet check: «» Missed Doses: «#» DWI: Yes «» No «» Carry days if applicable: «#» Deliveries allowed: Yes «» No «» Current pharmacy: «» Substance Last Used Amount/Freq Route Other Details Heroin «» «» «» «» «Opiate» «» «» «» «» Crack Cocaine «» «» «» «» Cocaine (powder) «» «» «» «» BZD «» «» «» «» ETOH «» «» «» «» Crystal Meth «» «» «» «» «Other» «» «» «» «» Objective: Blood pressure Appearance: Alert «» Drowsy «» Pupil: normal «» dilated «» Track marks: Not Reviewed «» OR; None «» Arms «» Legs «» Neck «» Counseling? «» Last UDS: «Letter.Patient.Macro.LASTUDS» Length of last Rx.? «» wk(s) swi«to record withdrawal or intoxication signs replace this with backslash \» Assessment/Plan: «» Length of this Rx «» wk(s) Rx expires on: «» |
| OUTN | Outreach - Not Successful | |
| OUTS | Outreach - Successful | |
| OWMPD | Onsite Withdrawal Management Discharge | |
| OWMPF | Onsite Withdrawal Management Follow-up | |
| OWMPI | Onsite Withdrawal Management Intake | |
| P | Template (SOAP) - Basic Visit (AccelEMR) | Subjective: «» Objective: «» Assessment / Plan: [Follow up «Letter.Patient.Next Appointment.Date»] with [«Letter.Patient.Next Appointment.ProviderName»] «» «» |
| P3 | P3 ANY RF Thanks! | P3 ANY RF Thanks! |
| PA | PrEP Assessment | PrEP Assessment See CPS STI Form and PrEP Assessment Form HIRI score: «» HIV PrEP discussed: «interested»«declined/deferred» Plan: Handout/web info given «» Discussed risk reduction «» «PrEP consult booked»«Client will access PrEP elsewhere» «Declined: plan to discuss PrEP again at next visit» «Barriers to access:» |
| PAHA | Nursing intake and screening labs reviewed | Nursing intake and screening labs reviewed. |
| PAING | Pain Services - Group | |
| PAINI | Pain Services - Information | Please contact us to book an appointment: PHONE or TEXT: 604.209.2781 or EMAIL: PainTeam@vch.ca or ASK YOUR CLINIC TO HELP YOU BOOK AN APPOINTMENT Pain Services Address: #208 – 524 Powell Street, Vancouver, BC V6A 3B3 |
| PAINM | Pain Services - myoActivation | |
| PAINP | Pain Services - Physiotherapy | |
| PAL | Palliative Care Clinical Service | |
| PALH | Hospice | Patient being seen in Hospice, please refer to the Hospice Chart. |
| PALMM | Dictation via MModal - see CareConnect | Patient seen and note dictated. See CareConnect or documents in Profile EMR. |
| PANSS | PANSS-SV | |
| PAP | Template - Pap Exam (calls PAPTEXT) | |
| PAPAB | Abnormal PAP | Abnormal PAP; tasked to CPS-EPID Priority |
| PAPN | Template - Pap Exam (calls PAPNTEXT) | |
| PAPNTEXT | Template - Pap Exam (TEXT ONLY) | Pap/Breast Exam Subjective: Menstrual Cycle (N/Menopausal/problem): «» Last Known Menstrual Period: «» Date of Last Pap «» Sexually Active: «Yes» Sexual Partner(s) (Male/Female/Trans): «» Method of Contraception: «» HPV Vaccine (Yes/No): «» History of Abnormal Paps (Yes/No): «» Recent Gyne Procedures (Yes/No): «» G «» P «» T «» A «» L «» Objective: Breasts «normal» Neck & Axillae «normal» Cervix «normal» Vulva «normal» Vaginal canal «normal» Uterus «normal» Adnexa «normal» External Genitalia «normal» Ano-Rectal «» KOH/Whiff Test «» |
| PAPOD | Overdue PAP | PAP Overdue. PAP reminder letter |
| PAPS | Template - Pap Exam (calls PAPSTEXT) | |
| PAPSTEXT | Template - Pap Exam (TEXT ONLY) | Pap/Breast Exam Subjective: Menstrual Cycle (N/Menopausal/problem): «» Last Known Menstrual Period: «» Date of Last Pap «» Sexually Active: «Yes» Sexual Partner(s) (Male/Female/Trans): «» Method of Contraception: «» HPV Vaccine (Yes/No): «» History of Abnormal Paps (Yes/No): «» Recent Gyne Procedures (Yes/No): «» G «» P «» T «» A «» L «» Objective: Breasts «normal» Neck & Axillae «normal» Cervix «normal» Vulva «normal» Vaginal canal «normal» Uterus «normal» Adnexa «normal» External Genitalia «normal» Ano-Rectal «» KOH/Whiff Test «» |
| PAPTEXT | Template - Pap Exam (TEXT ONLY) | Pap/Breast Exam Subjective: Menstrual Cycle (N/Menopausal/problem): «» Last Known Menstrual Period: «» Date of Last Pap «» Sexually Active: «Yes» Sexual Partner(s) (Male/Female/Trans): «» Method of Contraception: «» HPV Vaccine (Yes/No): «» History of Abnormal Paps (Yes/No): «» Recent Gyne Procedures (Yes/No): «» G «» P «» T «» A «» L «» Objective: Breasts «normal» Neck & Axillae «normal» Cervix «normal» Vulva «normal» Vaginal canal «normal» Uterus «normal» Adnexa «normal» External Genitalia «normal» Ano-Rectal «» KOH/Whiff Test «» |
| PARTNERS | Sexual Partners | · gender of sexual partners: · # of notifiable partners: «» · # of anonymous partners: «» · Partner notification: |
| PC | Template - Patient Conference (AccelEMR) | Patient Conference (14077) - Discussion with: «» Subjective: «» Assessment / Plan: Follow up «Letter.Patient.Next Appointment.Date»«» «» |
| PCCLOSE | PC CLOSE (calls PCCLOSETEXT) | |
| PCCLOSETEXT | PC CLOSE (TEXT ONLY) | • Last known contact attempted by phone/email «» • CareConnect reviewed «» • Pharmanet reviewed «» • Outreach considered «» • Client is connected to PCP in community «» • Pharmacy contacted if known «» • Reviewed other teams that client connected to (OOT, STOP, ACT, IHOT, STEPS..) «» • Client has moved «» • Client is with corrections services «» • Client is deceased «» • Letter sent to last known address «» • If client reconnects with CHC within 12 months: o meets mandate; reopen to previous MRP/POS «» o non mandate, living in Vancouver; refer to DOFP and resume care until connected«» o has community provider; redirect to their PCP«» o screen for mandate«» o review with team/clinic lead«» |
| PCIS | PC New Intake Note (calls PCISTEXT) | |
| PCISTEXT | PC New Intake Note (TEXT ONLY) | Subjective: Review Referral Form and Mandate Screen (Past Medical hx) Pronouns: «» Gender identity (it's ok if you do not want to disclose, we ask everyone): «» Current medical status: Chief concerns: «» Review Medinet (meds\): «» Conduct Best Possible Medication History: Allergies: «» Current meds: «» Relevant previous meds: «» Taking meds as prescribed: «» OTC meds: «» Nutrition/Dentition: «» Vision: «» Mental Health Diagnoses and Concerns: «» Sexual Health: «(contraception, STI screening)» Routine Screening: «(FIT, PAP, mammogram, A1C): type prevent\» Immunization review: «» Current substance use (Prescription or non-prescription drugs, including ETOH & Nicotine, frequency, route): «» Current OAT (include dosing): «» History of substance use: «» Detox/Treatment: «» Previous overdoses: «» Has THN kit/training?: «» Safer Substance Use Plan: «(may use opsp\)» Family medical hx: Cancers (colon, breast, cervix): «» Diabetes: «» HTN: «» Heart disease: «» Mental health: «» Social history (Add to Social/Risk Problem list) Do you self-identify as Aboriginal/First Nations/Metis or Inuit?: «» Status or non-status?: «» Status # (input into Problem List under "Administrative"): «» Emergency Contact and Next of Kin (Document in Registration Form): «» Identified Social Work Needs: «» Objective: Weight: «» Height: «» BP: «» PR: «» O2sat: «» Temp: «» Physical exams/Review of Systems: «» MSE: «» COWS/CIWA: «» Client Goals (what would they like to address while they are clients in Primary Care): 1. «» 2. «» 3. «» 4. «» A/P: Bloodwork/urine: «(may use PC Intake BW Set)» ROI: «printed out and signed by client» F/U appt booked |
| PCM | PC Mandate Screening (calls PCMTEXT) | |
| PCMTEXT | PC Mandate Screening (TEXT ONLY) | See documentation in form |
| PCN1C | PCN1 Counsellor Visit | |
| PCN1CD | PCN1 Discharge Note - CC | |
| PCN1D | PCN1 Dietitian Visit (calls PCN1DTEXT) | |
| PCN1DD | PCN1 Discharge Note - RD | |
| PCN1DTEXT | PCN1 Dietitian Visit (TEXT ONLY) | Reason for referral:«» Subjective Diet History: «» Activity: «» Objective Pertinent Labs: «» Pertinent Medications: «» Supplements: «» Medical history: «» Assessment Education: «» Plan/Recommendations «» |
| PCN1O | PCN1 Occupational Therapist Visit | |
| PCN1OD | PCN1 Discharge Note - OT | |
| PCN1OR | PCN1 Outward Referral | |
| PCN1P | PCN1 Clinical Pharmacist Visit | |
| PCN1PD | PCN1 Discharge Note - RPH | |
| PCN1S | PCN1 Social Worker Visit | |
| PCN1SD | PCN1 Discharge Note - SW | |
| PCN2C | PCN2 Counsellor Visit | |
| PCN2CD | PCN2 Discharge Note - CC | |
| PCN2D | PCN2 Dietitian Visit (calls PCN2DTEXT) | |
| PCN2DD | PCN2 Discharge Note - RD | |
| PCN2DTEXT | PCN2 Dietitian Visit (TEXT ONLY) | Reason for referral:«» Subjective Diet History: «» Activity: «» Objective Pertinent Labs: «» Pertinent Medications: «» Supplements: «» Medical history: «» Assessment Education: «» Plan/Recommendations «» |
| PCN2O | PCN2 Occupational Therapist Visit | |
| PCN2OD | PCN2 Discharge Note - OT | |
| PCN2OR | PCN2 Outward Referral | |
| PCN2P | PCN2 Clinical Pharmacist Visit | |
| PCN2PD | PCN2 Discharge Note - RPH | |
| PCN2S | PCN2 Social Worker Visit | |
| PCN2SD | PCN2 Discharge Note - SW | |
| PCN3C | PCN3 Counsellor Visit | |
| PCN3CD | PCN3 Discharge Note - CC | |
| PCN3D | PCN3 Dietitian Visit (calls PCN3DTEXT) | |
| PCN3DD | PCN3 Discharge Note - RD | |
| PCN3DTEXT | PCN3 Dietitian Visit (TEXT ONLY) | Reason for referral:«» Subjective Diet History: «» Activity: «» Objective Pertinent Labs: «» Pertinent Medications: «» Supplements: «» Medical history: «» Assessment Education: «» Plan/Recommendations «» |
| PCN3O | PCN3 Occupational Therapist Visit | |
| PCN3OD | PCN3 Discharge Note - OT | |
| PCN3OR | PCN3 Outward Referral | |
| PCN3P | PCN3 Clinical Pharmacist Visit | |
| PCN3PD | PCN3 Discharge Note - RPH | |
| PCN3S | PCN3 Social Worker Visit | |
| PCN3SD | PCN3 Discharge Note - SW | |
| PCN4C | PCN4 Counsellor Visit | |
| PCN4CD | PCN4 Discharge Note - CC | |
| PCN4D | PCN4 Dietitian Visit (calls PCN4DTEXT) | |
| PCN4DD | PCN4 Discharge Note - RD | |
| PCN4DTEXT | PCN4 Dietitian Visit (TEXT ONLY) | Reason for referral:«» Subjective Diet History: «» Activity: «» Objective Pertinent Labs: «» Pertinent Medications: «» Supplements: «» Medical history: «» Assessment Education: «» Plan/Recommendations «» |
| PCN4O | PCN4 Occupational Therapist Visit | |
| PCN4OD | PCN4 Discharge Note - OT | |
| PCN4OR | PCN4 Outward Referral | |
| PCN4P | PCN4 Clinical Pharmacist Visit | |
| PCN4PD | PCN4 Discharge Note - RPH | |
| PCN4S | PCN4 Social Worker Visit | |
| PCN4SD | PCN4 Discharge Note - SW | |
| PCN5C | PCN5 Counsellor Visit | |
| PCN5CD | PCN5 Discharge Note - CC | |
| PCN5D | PCN5 Dietitian Visit (calls PCN5DTEXT) | |
| PCN5DD | PCN5 Discharge Note - RD | |
| PCN5DTEXT | PCN5 Dietitian Visit (TEXT ONLY) | Reason for referral:«» Subjective Diet History: «» Activity: «» Objective Pertinent Labs: «» Pertinent Medications: «» Supplements: «» Medical history: «» Assessment Education: «» Plan/Recommendations «» |
| PCN5O | PCN5 Occupational Therapist Visit | |
| PCN5OD | PCN5 Discharge Note - OT | |
| PCN5OR | PCN5 Outward Referral | |
| PCN5P | PCN5 Clinical Pharmacist Visit | |
| PCN5PD | PCN5 Discharge Note - RPH | |
| PCN5S | PCN5 Social Worker Visit | |
| PCN5SD | PCN5 Discharge Note - SW | |
| PCN6C | PCN6 Counsellor Visit | |
| PCN6CD | PCN6 Discharge Note - CC | |
| PCN6D | PCN6 Dietitian Visit (calls PCN6DTEXT) | |
| PCN6DD | PCN6 Discharge Note - RD | |
| PCN6DTEXT | PCN6 Dietitian Visit (TEXT ONLY) | Reason for referral:«» Subjective Diet History: «» Activity: «» Objective Pertinent Labs: «» Pertinent Medications: «» Supplements: «» Medical history: «» Assessment Education: «» Plan/Recommendations «» |
| PCN6O | PCN6 Occupational Therapy Visit | |
| PCN6OD | PCN6 Discharge Note - OT | |
| PCN6OR | PCN6 Outward Referral | |
| PCN6P | PCN6 Clinical Pharmacist Visit | |
| PCN6PD | PCN6 Discharge Note - RPH | |
| PCN6S | PCN6 Social Worker Visit | |
| PCN6SD | PCN6 Discharge Note - SW | |
| PCNMHSU | PCN MHSU Collaborator Discharge Note | |
| PCNREF | Referral Email Confirmation Receipt (calls PCNREFTEXT) | |
| PCP | Template - Palliative Care Plan (AccelEMR) | PALLIATIVE CARE PLAN (14063 - 30 minutes min + visit time) Reviewed EMR (Summary, Results, Documents, Encounters) Reviewed Diagnosis - Palliative; Pt agrees to no longer seek Tx aimed at cure. Reviewed medication issues - affordability, S.A., compliance, refills (* Add "Rx(spacebar)" to Social Problems prn) Reviewed end of life issues - degree of intervention, power of attorney, living will (* Add "DOI" to Social Problems prn) Updated patient's Personal Health Goals (* Add "Goal" to Social Problems prn) Identified Barriers to achieving goals (* Add "Barrier" to Social Problems prn) Health Care Needs: «» Symptom Mgt Plan: «» (Note to Provider - Go to Forms and in the Browse field type "pall" for a list of all the Palliative Care Forms) Palliative Care Team Referral done: «yes»«no» Palliative Care Benefits Form sent: «yes»«no» DNR order written and given to patient: «yes»«no» |
| PDM | Opens Diabetes Clinic Visit - MDI | |
| PDP | Opens Diabetes Clinic Visit - Pump | |
| PE | Peer Engagement | |
| PEAK | Peak House Youth Treatment Program (Macro only) | |
| PEDS | Template - Visit - Pediatric, New Consult (calls PEDSTEXT) | |
| PEDS2 | Template - Visit - Pediatric, Follow-up (calls PEDS2TEXT) | |
| PEDS2TEXT | Template - Visit - Pediatric, Follow-up (TEXT ONLY) | ID: «» HPI: «» Physical Exam: «» Impression/Plan: «» |
| PEDSTEXT | Template - Visit - Pediatric, New Consult (TEXT ONLY) | ID: «» HPI: «» PMH: «» o Pregnancy/Delivery: «» o Development: «» Meds: «» Allergies: «» Immunizations: «» Family/Social History: «» Physical Exam: «» Impression/Plan: «» |
| PEP | HIV Post Exposure Prophylaxis PEP | HIV Post Exposure Prophylaxis PEP Clinic Visit Subjective: Client reports potential exposure to HIV Date and time of exposure: «» Type of exposure: «blood» «semen» «vaginal secretions» «rectal secretions» «percutaneous» «other body fluid:» Source HIV status: «negative» «positive» «unknown» «source from major risk group:» Risk assessment as per BCCfE algorithm: «No risk» «Probable major risk» «» Offer sexual assault services prn: «N/A» «accepted» «declined» Sexual health history: «see CPS STI Form» Past medical history: «healthy» «other» Allergies: «NKDA» «other» Regular medications: «none» Health coverage: «MPS» «none» «other» Objective: Physical exam: «not indicated» «no variances, see CPS STI Form» «variances noted:» HIV POC: «result» Assessment: «Probable risk for HIV; PEP indicated» «PEP not indicated» Plan Consulted with MD for PEP order: «Dr.» PEP baseline bloodwork: Additional STI testing: PEP 5 day starter kit dispensed. First dose STAT. Drug-drug interactions: «none» «other» Harm reduction discussed. Client education: PEP meds, risks/benefits, side effects, follow up recommendations: HIV testing 3, 6, 12 weeks after PEP completion Follow up appointment with MD/NP Booked: «Date/Time» PEP form completed; admin to fax and scan into EMR |
| PEPFU | PEP Follow Up | Subjective: Date/Time HIV PEP Started: «» 5-day starter kit dispensed from: «» Exposure Date/Time: «» Nature of exposure: «» Characteristics of Source: «» Baseline Labs Review: «» HIV PEP adherence: «» Side effects/concerns: «» Objective: Client wellbeing: «» HIV Risk Assessment per BC CfE HIV PEP Guidelines: «» Assessment/Plan: Client to continue with remaining 23-day course of HIV PEP Reviewed potential side effects: headache, insomnia, fatigue, dizziness, abdominal pain, myalgia, nausea, vomiting, and diarrhea Client aware to contact SPH Pharmacy if they have further questions or concerns while on PEP Client aware to pick up prescription later today Aware to complete follow up HIV Ag/Ab testing at 3, 6, and 12 weeks post completion of the 28-day regimen. PEP Follow Up & Prescription form faxed to SPH/BC CfE |
| PEPPH | PEP Assessment Phone Call | PEP Assessment Phone Call Subjective: Client called nurse line; reports potential exposure to HIV Date and time of exposure: «» Type of exposure: «blood» «semen» «vaginal secretions» «rectal secretions» «percutaneous» «other body fluid:» Source HIV status: «negative» «positive» «unknown» «source for major risk group:» Risk assessment as per BCCfE algorithm: «No risk» «Probable major risk» «» Assessment: «Probable risk for HIV; PEP indicated» «PEP not indicated» Plan: «Client education re: PEP meds, time sensitive nature (asked to be triaged as urgent)» Client plans to go to «ER» «655 Clinic» «other PEP site» «PEP not indicated: counselling offered; discussed harm reduction and PrEP if applicable; discussed follow-up recommendations:» |
| PEPTR | PEP Triage | PEP triage • Date and time of exposure: • Date and time of PEP initiation: • Do you have follow up with a primary care provider • 5 day kit issued by: (which hospital? Or clinic) • Type of exposure: sexual exposure sexual assault other • Pep follow up indicated • PEP follow up booked: For Risk assessment See Form : BC-Cfe HIV post exposure prophylaxis follow up and prescription form |
| PERSEL | PERSEL | persistently elevated RPR titre with negative lumbar puncture |
| PGR | Psychiatry Grand Rounds | Psychiatry Grand Rounds: Client reviewed with multidisciplinary team. Teams/persons involved in care: • Updates/concerns: • Plan/Action Items: |
| PH208 | Phone 208 | PH208 call received from «TA Clinic» Positive «GC/CT» result verified, diagnosis entered on H208 tab. Hard copy of lab result given to Admin for verification Follow-up initiated to inform client, arrange treatment and discuss partners |
| PHA | Template - Pharmacare - Special Authority Request (AccelEMR) | Pharmacare - Special Authority Request SA approval obtained by phone for «» (1-877-657-1188) |
| PHARM | Shows Client's Preferred Pharmacy | Client's Preferred Pharmacy: «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").FullName» «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").AddressStreet» Phone: «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").Phone1» Fax: «Letter.Patient.CareTeam("Pharmacy (Supplier) - Preferred").Fax» |
| PHC | PH208 Result Confirmed | PH208 Result Confirmed |
| PHCON | Phone call: contact to STI | Phone call re: contact to STI Informed client that they were named as a contact to: «CT/GC/Syphilis/HIV/other» Education provided as per STI DST Testing and treatment recommended Plan: «Will come to BCCDC clinic: Epid appointment booked»«Will follow-up with other healthcare provider/clinic» |
| PHNEG | Phone results: negative | Phone call received from client requesting results Results provided and discussed |
| PHOTO | Invokes photo form | |
| PHPOS | Phone results: positive | Phone call to client re: positive result Informed re: «CT/GC/Syphilis/other» Client education provided as per STI DST Treatment plan: «will come to clinic: EPID appointment booked»«other» Partner notification: «client will inform»«BCCDC PHN to inform: contact info documented in CM tab of STI form» |
| PHRA | Personal health risk | Personal health risk assessment (G14066): Age: «» Gender: «» Dx code (783 – unhealthy eating or obesity, 785 – sedentary, 786 – smoking): «» Substances: smoking: «» alcohol intake: «» drug use: «» Cancer screening: Colon: «» Breast: «» Cervix: «» Lung: «» Prostate: «» Anal: «» Chronic diseases HTN: «» Dislipidemia: «» Diabetes: «» Bone density: «» STI: «» Vaccines reviewed: (flu, pneumo, Td, HPV, HZV, HAV, HBV, etc) - «» Food secure? : «» Housing: «» Counseling/Plan: Diet: «» Physical activity: «» Sexual health: «» Connection to financial resources/soc support: «» Lifetime Prevention Schedule: «» |
| PHVH | Template - Preventive Health Visit-History (AccelEMR) | Preventive Health Maintenance Visit Lifestyle: Diet - «healthy»; Alcohol - «less than 1 drinks/day»; Exercise - «more than 3 times a week»; Smoking - «none»; Stress - «minimal» Symptoms: Sleep - «normal»; Energy - «normal»; Mood - «normal» Concerns: «» Wellness Goals: «» |
| PHVP | Template - Preventive Health Visit - Plan (AccelEMR) | «FOB»; «Lab»; Follow up for «» |
| PHYO | Physician: Outreach | |
| PHYS | Physician Positive | MD to review. Tasked to CPS Physician |
| PIA | Psychiatric Assessment Version 4 (PA) | |
| PIE | Initial Person-in-Environment Assessment | Initial Person-in-Environment Assessment During the assessment, this writer informed the client of the scope and limitations of confidentiality including access to medical record, VCH electronic charting system, and duty to report. 1. PIE Factor I _ Problems in Social Role Functioning: Social interaction areas and social roles functioning «» · Familial (parent, spouse, child, sibling, significant other): · other interpersonal (lover, friend, neighbor, etc.): · occupational (worker/paid, worker/home, volunteer, student): · special life situation (consumer, inpatient/client, outpatient/client, probationer/parolee, prisoner, legal: · immigrant, undocumented immigrant, refugee, other): The types of problem (power, ambivalence, responsibility, dependence, loss, isolation, and/or victimization.): The severity of each problem. This is noted on a scale of 1 (lowest) to 6 (highest). The duration of each problem (how long each problem has been present). This is noted on a scale of 1 (five years or longer) to 6 (two weeks or less). Clinical judgment of the client’s physical, mental, and psychological strength to cope with the problem. This is noted on a scale of 1 (outstanding) to 6 (no coping skills). 2. PIE Factor II - Problems in the Environment: Nature of the environmental or social system problem «» · Economic/basic need system (problems in the provision or accessibility of food, shelter, employment, economic resources, and transportation): · educational and training system (problems or deficiencies related to education/training institutions and policies: · Judicial and legal system (problems related to the police and courts): · Health, welfare, and safety system (problems related to hospitals, clinics, public safety services, and social services): · Voluntary association system (problems related to religious institutions and community support groups): · Affectional support system (problems related to the helping network): The severity of each problem, on a scale of 1 (lowest) to 6 (highest). The duration of each problem, on a scale from 1 (five years or longer) to 6 (two weeks or less). 3. PIE Factor III - Mental Health Problems: «» DSM 5 codes 4. PIE Factor IV - Physical Health Problems: «» These problems may be ones diagnosed by a physician and/or reported by the client. For official diagnoses, you use DSM or ICD 10 codes. |
| PN | Pharmacy Note | |
| PN1 | prenatal initial labs | cbc, ferritin, urine c+s, tsh rubella titre, syphillis serology, hiv test, anti hcv, varicella igG, hbsAg, hbsAb b12 level Hemoglobin A1c if high bmi hemoglobin electrophoresis + hplc blood grouping and ab screen (ABO +RH) |
| PN2 | prenatal bloodwork-28 weeks | cbc, ferritin, 1 hr gtt, ct/gc urine abo + rh and antibody screen if rh negative |
| PNDC | PSS (Personalized Support & Stabilization) LGH – Discharge Note | |
| PNDCH | Pharmacy Note - DCHC | |
| PNDTC | Pharmacy Note - DTES Connections | |
| PNFC | PSS (Personalized Support & Stabilization) LGH – First Contact | |
| PNOC | PSS (Personalized Support & Stabilization) LGH – Ongoing Care | |
| PNSPEC | Pharmacist Note – Specialty Clinic | |
| PO | Template - Pre-Op Physical (AccelEMR) | Relevant Functional Enquiry: «Neg» Past Anesthesia Problems: «None» Hospitalized in past 3 months: «No» MRSA positive in the past year: «No» Head & Neck: «Normal» Lungs: «Normal» CV: «Normal» Abdomen: «Normal» MSK: «Normal» Other Relevant findings: «None» Analysis/Plan/Comments: «The health of this patient is adequate to proceed with the planned surgery» |
| POAT | Pender OAT Template for TBC | Subjective: • Primary concern «» • Client goals «» • Current opiate agonist therapy (incl. dose) «suboxone/methadone/other/none» • Current dose working? «» • Current Substance use «BZD, EtOH, cocaine, CM, opiates, THC, tobacco» • Quality of Life «home, food, social, work, volunteer» • Overdoses in last 30 days: «» • Has THN training: «yes/no» • Has THN kit: «yes/no» • Harm Reduction/Safety: «SCS, drug checking, using alone?» • Medinet reviewed: «yes/no» • Missed doses in the past seven days? «yes/no and which days» • Contraception «» • Mood «» Objective: • «LOC, drowsy, alert» • Last Urine Drug Screen: «Letter.Patient.Macro.LASTUDS» • Last HIV-1 and HIV-2 Antibody and Antigen: «Letter.Patient.Macro.LASTHIV12ABP24» • Last HCV AB: «Letter.Patient.Macro.LASTHCAB» Assessment/Plan: 1. OUD – see form, to f/u «» |
| POCA1C | Hemoglobin A1C/Total Hemoglobin; POC Testing (calls POCA1C) | |
| POCA1CTEXT | Hemoglobin A1C/Total Hemoglobin; POC Testing (TEXT only) | Test Date [DD MMM YYYY]: «Letter.Letter.Today» Test Time [HH:MM]: «» Device Operator: «Letter.LoggedOnUser.FullName» Ordering Provider: «» Test Result: «»% Result Flag: «H for High; L for Low; None» Reference Range: 4.0-6.0% Therapeutic target for children and adolescents with type 1 diabetes is < or equal to 7.5%. For most children with type 2 diabetes, target is < or equal to 7.0%. See 2018 Diabetes Canada guidelines. Analysis was performed on a whole blood specimen using a point of care device. |
| PODC | POR Discharge (calls PODCTEXT) | |
| POSTIOAT | VCH - Nurse Post-Assessment iOAT (calls POSTIOATTEXT) | |
| POSTIOATTEXT | VCH - Nurse Post-Assessment iOAT (TEXT ONLY) | Post-Dose iOAT Assessment Severely anxious or agitate(Y/N/U): «» Dyskinectic(Y/N/U): «» Overly sedated(Y/N/U): «» Slurred speech(Y/N/U): «» Smells of alcohol(Y/N/U): «» Decreased respiration rate(Y/N/U): «» rr «» Pasero Opioid-induced Sedation Scale (POSS) level: «» Notes: «» |
| POSTOPM | Post-Operative Care: Metoidioplasty (calls POSTOPMTEXT) | |
| POSTOPMTEXT | Post-Operative Care: Metoidioplasty (TEXT ONLY) | Subjective: Surgery date: «» Surgeon: «» Weeks post-op: «» Primary Concern: «» Post-op infection review: «» «risk factors/education» Pain management: «» Complications: «fistula/stricture, wound dehiscence, catheter care etc.,» Bowel care: «» Genitourinary care: «» Level of activity: «» Psychosocial check-in: «» Objective: «» Assessment: «» Plan: [Follow up «Letter.Patient.Next Appointment.Date» ] with [«Letter.Patient.Next Appointment.ProviderName» ] «» |
| POSTOPP | Post-Operative Care: Phalloplasty | Subjective: Surgery date: «» Surgeon: «» Weeks post-op: «» Primary Concern: «» Post-op infection review: «» «risk factors/education» Pain management: «» Complications: «fistula/stricture, wound dehiscence, catheter care etc.,» Bowel care: «» Genitourinary care: «» Level of activity: «» Psychosocial check-in: «» Objective: «» Assessment: «» Plan: [Follow up «Letter.Patient.Next Appointment.Date» ] with [«Letter.Patient.Next Appointment.ProviderName» ] «» |
| POSTOPV | TSC-Post-Operative Checklist: Vaginoplasty (calls POSTOPVTEXT) | |
| POSTOPVTEXT | TSC - Post-Operative Checklist: Vaginoplasty (TEXT only) | Subjective: Surgery date: «» Surgeon: «» Weeks post-op: «» Client reminder: Complete bloodwork and book hormone follow-up with MD/NP at 4 weeks post-op Primary Concern: «» Post-op infection review: «» «risk factors/education» Dilation: «» Discharge: «» Pain management: «» Complications: «hypergranulation, wound dehiscence, catheter care etc.,» Bowel care: «» Genitourinary care: «» Level of activity: «» Psychosocial check-in: «» Objective: «» Assessment: «» Plan: [Follow up «Letter.Patient.Next Appointment.Date»] with [«Letter.Patient.Next Appointment.ProviderName» ] «» |
| PP | Copy to Physician | Previous Copy to Clinic Physician |
| PPDN | PSS Plus (Personal Support & Stabilization) LGH - Discharge | |
| PPFC | PSS Plus (Personal Support & Stabilization) LGH - First Contact | |
| PPFU | Pandemic Prescribing Follow Up | Pandemic Prescribing Follow Up Contact info checked/up to date? «» Significant reduction in wds & cravings? «» Increased capacity to self-isolate? «» Decreased reliance on street drug supply? «» Reduction in overdose risk (via reduced exposure to toxic drug supply)? «» No adverse effects from prescribed substances? «» Safe storage of medications? «» Actions taken: «» Checked if pt has a primary care provider? (Y/N) «» Discussed criteria for pandemic prescribing? (Y/N) «» HR counselling provided? (Y/N) «» Does patient have a handout? (Y/N) «» |
| PPOC | PSS Plus (Personal Support & Stabilization) LGH - Ongoing Care | |
| PPOS | Previously Positive | Previously Positive |
| PRDC | PSS (Personalized Support & Stabilization) RH – Discharge Note | |
| PRE | Pre-Natal Care | Pre-Natal Care Diagnosis: «» Due Date: «» Bicillin Treatment Complete: «» Dose 1: «» Dose 2: «» Dose 3: «» OB/GYN/MW: «» * Handout sent: «» * Requisition mailed: «» * Reminder call at 36 weeks: «» Recommended Bloodwork: Date: «» Date: «» Date: «» Date: «» Family (see CM tab for names and DOB): * Partner(s) BW: «» * Partner(s) Tx: «» * Child 1 BW: «» * Child 2 BW: «» * Child 3 BW: «» At Birth: * Contact chart for baby: «» * Mom and baby charts linked: «» Mom's RPR: «» Baby's RPR: «» Reminders: * Sign when completed Add the EDD to EMR Banner Enter EDD on hardcopy calendar |
| PREIOAT | VCH - Nurse Pre-Assessment iOAT (calls PREIOATTEXT) | |
| PREIOATTEXT | VCH - Nurse Pre-Assessment iOAT (TEXT ONLY) | Pre-Dose iOAT Assessment Severely anxious or agitate(Y/N/U): «» Dyskinectic(Y/N/U): «» Overly sedated(Y/N/U): «» Slurred speech(Y/N/U): «» Smells of alcohol(Y/N/U): «» Baseline rr «» Pasero Opioid-induced Sedation Scale (POSS) level: «» Breathalyzer required(Y/N): «» If yes, breathalyzer reading: «» Notes: «» |
| PREN | Template - Prenatal Measures (AccelEMR) | Prenatal Measures: Urine Dip: Glucose: «» Protein: «» Measures: Wt «kg», BP «» (Recorded by: «initials») |
| PREOPM | Pre-Operative Check List: Metoidioplasty (calls PREOPMTEXT) | |
| PREOPMTEXT | Pre-Operative Check List: Metoidioplasty (TEXT ONLY) | Subjective: Surgery date: «» Psychosocial check-in/Mental health assessment «» Flight details (if out of country/province): «» Support and care plan upon return: «» Financial plan: «medical EI etc.,» Medication (pre-op and post-op instructions): «» Diet: «vegetarian, vegan, etc.,» Post-Operative supplies: «» Urology referral submitted? «Y/N» Post-operative urology appointment date: «» Co-morbidities affecting wound healing? «» Surgery (review): «» Complications (review): Urethral Fistula: «» Urethral Stricture: «» Wound Dehiscence: «» Surgical Site infection: «» Urinary Tract Infections or Cystitis: «» Pain management: «» Bowel movements: «» Catheter care: «» Activity level: «» Objective: «» Assessment: «» Plan: [Follow up «Letter.Patient.Next Appointment.Date»] with [«Letter.Patient.Next Appointment.ProviderName»] «» |
| PREOPP | Pre-Operative Checklist: Phalloplasty (calls PREOPPTEXT) | |
| PREOPPTEXT | Pre-Operative Checklist: Phalloplasty (TEXT ONLY) | Subjective: Surgery date: «» Psychosocial check-in/Mental health assessment Flight details (if out of country/province): «» Support and care plan upon return: «» Financial plan: «medical EI etc.,» Medication (pre-op and post-op instructions): «» Diet: «vegetarian, vegan, etc.,» Post-Operative supplies: «» Urology referral submitted? «Y/N» Post-operative urology appointment date: «» Co-morbidities affecting wound healing? «» Surgery (review): «» Complications (review): Donor Site Graft Failure: «» Urethral Fistula: «» Urethral Stricture: «» Wound Dehiscence: «» Surgical Site infection: «» Urinary Tract Infections or Cystitis: «» Pain management: «» Bowel movements: «» Catheter care: «» Activity level: «» Objective: «» Assessment: «» Plan: [Follow up «Letter.Patient.Next Appointment.Date» ] with [«Letter.Patient.Next Appointment.ProviderName» ] «» |
| PREOPV | Pre-Op Teaching Checklist: Vaginoplasty (calls PREOPVTEXT) | |
| PREOPVTEXT | Pre-Op Teaching Checklist: Vaginoplasty (TEXT ONLY) | Subjective: Surgery date: «» Psychosocial check-in/Mental health assessment: «» Flight details (if out of country/province): «» Support and care plan upon return: «» Financial plan: «medical EI etc.,» Medication (pre-op and post-op instructions): «» Diet: «vegetarian, vegan, etc.,» Post-Operative supplies: «» Co-morbidities affecting wound healing? «» Surgery (review): «general swelling/bruising, stent etc.,» Complications (review): Hypergranulation: «» Infection: «» Urinary tract infection: «» Wound Dehiscence: «» Difficulty Dilating: «» Pain management: «» Discharge and Douching: «» Bowel movements and voiding: «» Dilations «review dilation schedule» Concerns? «discharge. discomfort etc.,» Activity level: «» Objective: «» Assessment: «» Plan: [Follow up «Letter.Patient.Next Appointment.Date» ] with [«Letter.Patient.Next Appointment.ProviderName» ] «» |
| PREP | PrEP Assessment New | HIV PRE-EXPOSURE PROPHYLAXIS -- BASELINE ASSESSMENT **Use F4 to tab through the «»** Gender: «» M, «» F, «» Trans «»F to M, «» M to F Regular GP: «» GP Name: «» Patient has spoke with GP regarding PrEP «» GP willing to prescribe PrEP «» PrEP Access Date (YYYYMMDD) of Referral (if applicable): «» Referred from: «» Self-referred «» Community Organization «» Sexual Health Clinic «» General Practitioner «» Medical/Public Health Officer «» Other: «» Prep Coverage (put an x by all that apply) Provincial PreP Program «» Private Insurance Coverage «» % Coverage «» Plan W Coverage (previously NIHB) «» Self-Funded PrEP «» Other «» Co-Morbidities (put an x by all that apply) Chronic Active Hepatitis B «» Hepatitis C «» Chronic Renal Impairment/CKD «» Diabetes «» Hypertension «» Depression/Anxiety «» Osteoporosis/Low Bone Mass «» Prior Use of NPEP «» Other Significant Issues?PMHx «» Describe: «» Prior STI’s Ever Gonorrhea: «» Yes, «» Rectal, «» Urethral, «» Pharyngeal, Date: «» Chlamydia: «» Yes «» Rectal, «» Urethral, «» Pharyngeal, Date: «» Syphilis: «» Yes, Date: «» HIV Risk (put an x by all that apply) MSM: «» HIRI >10 «» Prior Rectal STI and Syphilis «» Known HIV+ Partner where Viral Load is not <40: «» Injection Drug Use Partner where Viral Load is not <40: «» Other Factors «» Describe «» Condom Use (% of use for anal/vaginal sex): With Main Partner: «» 0, «» 10-50%, «» 50-80%, «» 80%, «» NA, «» Unknown With Casual Partners: «» 0, «» 10-50%, «» 50-80%, «» 80%, «» NA, «» Unknown For MSM: As Insertive Partner: «» 0, «» 10-50%, «» 50-80%, «» 80%, «» NA, «» Unknown As Receptive Partner: «» 0, «» 10-50%, «» 50-80%, «» 80%, «» NA, «» Unknown HIRI-MSM Risk Index Calculator (Score > 10 Suggests HIV Incidence > 2% in Vancouver) Question Response Value Score 1. Age in years? 18-28 yrs ---- 8 29-40 yrs ---- 5 41-48 yrs ---- 2 ≥ 49 yrs ---- 0 «» 2. # Male partners in past 6 months? > 10 partners ---- 7 6-10 partners ---- 4 0-5 partners ---- 0 «» 3. # HIV-positive male partners in past 6 months? > 1 partner ---- 8 1 partner ---- 4 < 1 partner ---- 0 «» 4. # TIMES having unprotected receptive anal sex in past 6 months? ≥ 1 time ---- 10 0 times ---- 0 «» 5. # TIMES having unprotected insertive anal sex with an HIV (+) partner in past 6 months > 5 times ---- 6 0-4 times ---- 0 «» 6. Methamphetamine use in past 6 months? Yes ---- 5 No ---- 0 «» 7. Poppers (Nitrate Insuflation) in past 6 months? Yes ---- 3 No ---- 0 «» Total HIRI Score: «» Substance Use in Last 6 Months Problem Alcohol Use: «» Yes, «» No, «» Unknown Crystal Methamphetamine: «» Yes, «» No, «» Unknown Cocaine or Crack: «» Yes, «» No, «» Unknown GHB: «» Yes, «» No, «» Unknown Ketamine: «» Yes, «» No, «» Unknown Heroin or other Opiates: «» Yes, «» No, «» Unknown Ecstasy: «» Yes, «» No, «» Unknown Laboratory at Baseline Date: «» CBC Normal «» HB SAg+ «» Yes, «» No, «» Unknown Creatine «» HB SAb Titre > 10 (Hep B Immune) «» Yes, «» No, «» Unknown eGFR «» HCV Antibody: «» positive, «» Negative T. pallidum EIA: «» RPR Titre: «» HIV Ab/Ag EIA «» (NB: Window Period is 14-21 days) Action PrEP Prescribed? «» Yes, «» No if No, why not «» PrEP Deferred? «» Yes, «» No If Yes, «» risk event within HIV test window period (awaiting repeat test results) «» awaiting baseline labs «» Awaiting coverage «» Other reasons «» Date Prescribed: «» (YYYYMMDD) «» Daily PrEP «» On-demand PrEP Counseling: «» Condoms «» Harm Reduction «» Side Effects/Renal Monitoring «» Adherence «» HIV/STI Required q3 mo «» Weight-bearing Exercise «» Report Seroconversion Symptoms «» Vitamin D «» Follow-up in 30 Days Arranged Vaccines Dose 1 Dose 2 Dose 3 Hepatitis A «» «» NA Hepatitis B «» «» «» HPV («» 4 Valent «» 9 Valent) «» «» «» |
| PREP1 | PrEP Start Assessment (calls PREP1TEXT) | |
| PREP1M | PrEP 1 month visit | PrEP 1-month visit - Patient in for PrEP 1 month follow-up. - Type of visit: «in-person, phone or Zoom» - No reported issues/adverse events. Tolerating medication well. - Adherence excellent: «no missed doses» - Pills remaining: «» - Bloodwork reviewed: «no issues» A/P: - Continue with tenofovir disoproxil fumarate/emtricitabine. - Adherence reinforced, as well as importance of bone protection measures (e.g. Vitamin D) and condom use for prevention of other STIs. - Gave 3-monthly standing order lab requisition: To be done a week prior to each visit For HIV, syphilis, creatinine/GFR, urine ACR Plus Q 12 months HCV testing - Gave instructions for accessing refill Rx - Faxed refill Rx to the CfE. Pick up date/location: «» - Appointment made for next 3-month visit: «» Type of visit: «in-person, phone or Zoom» Added to Memora: «» |
| PREP1TEXT | PrEP Start Assessment (TEXT ONLY) | PrEP Start Assessment *Use F4 to tab through the «»* *Add to problem list and code encounter as V01 – HIV PrEP RN Led or HIV PrEP Prescriber Led* PrEP Baseline Labs, collection date: «» Out of Range Lab Results: «» - Action (Consult with DOD): «» HIV negative result confirmed «» Risk for HIV transmission from 14 days prior to baseline labs until present? «» If yes, describe (assess for PEP): «» BP today: «» Health History: «» Medications: «» ** Add to EMR Problem List, Usual Prescriptions** Allergies: «» ** Add to EMR Adverse Reaction box** Substance Use: «» - Action (Referrals to supports, as appropriate): «» PrEP Counseling: «» Condoms «» Harm Reduction «» Dosing (loading dose to start) «» Adherence/Missed Doses «» Side Effects/Renal Monitoring «» Weight-bearing Exercise/Vitamin D «» HIV/STI Required q3 mo «» Report Seroconversion Symptoms «» Vaccines (HAV/HBV/MPOX/HPV) PrEP Rx Deferred? : «» Yes, «» No If Yes, «» Risk event within HIV test window period (awaiting repeat test results) «» Awaiting baseline labs «» Awaiting coverage «» Other reasons «» PrEP Prescribed:«» Yes, «» No «» Enrolment Form completed «» One month follow up lab requisition given «» Client encouraged to discuss PrEP Primary Care Provider Follow-up «» Follow-up in 30 Days with at HIM; date: «» OR «» Primary care Provider willing to prescribe PrEP |
| PREP3M | PrEP 3 month visit | 3 monthly PrEP visit - Patient in for PrEP 3 month follow-up. - Type of visit: «in-person, phone or Zoom» - No reported issues/adverse events. Tolerating medication well. - Adherence excellent: «no missed doses» - No changes in medical hx/meds/allergies - Pills remaining: «» - Bloodwork reviewed: «no issues» A/P: - Continue with tenofovir disoproxil fumarate/emtricitabine. - Swabs done for CT/GC NAT throat + rectum - Adherence reinforced, as well as importance of bone protection measures and condom use for prevention of other STIs. - Gave instructions for accessing refill Rx - Ensured patient has a standing order at a lab. Current order valid until: «» - Faxed refill Rx to the CfE. Pick up date/location: «» - Appointment made for next 3-month visit: «» Type of visit: «in-person, phone or Zoom» Added to Memora: «» |
| PREPBL | HIV PrEP Baseline Assessment(Calls PREPBLTEXT) | |
| PREPBLTEXT | HIV PrEP Baseline Assessment(TEXT ONLY) | Client attached to Primary Care Provider (Y/N): «» MSP active (Y/N): «» Previous HIV PrEP use (Y/N): «» Risk Factors & Eligiblity: Hiri Score (gbMSM and Transwomen only): «» Hx of PEP use ≥ 2 (Y/N): «» Previous syphilis (Y/N): «» Previous positive rectal CT or GC (Y/N): «» Other: Sexual partner living with HIV with detectable viral load (Y/N): «» Cis-hetero male/female not eligible for HIRI. Discussed with MD/NP and approved for intake (Y/N): «» Medical History: Ongoing chronic illness/medical issues: «» Allergies: «» Current medications and supplements: «» Follow-up Planning: PrEP Intake appointment booked (Date/Time): «» Baseline lab requisition provided. Aware to complete between 7-14 days prior to intake appt (Y/N): «» Task sent to ADMIN to add client and appointment reminder to Memora (Y/N): «» |
| PREPFU | HIV PrEP Follow UP Visit (calls PREPFUTEXT) | |
| PREPFUTEXT | HIV PrEP Follow UP Visit (TEXT ONLY) | HIV PrEP F/U visit Subjective: New changes to health or new medications since last appointment (describe): «» Takes PrEP «» daily «» on-demand Adherence: «» no missed doses «» takes on demand PrEP correctly (2-1-1) «» missed 1-2 doses «» had a treatment interruption / taking incorrectly (describe): «» Side effects: «» none «» some side effects (describe): «» Amount of pills left «» STI symptoms (describe): «» STI contacts (describe): «» Objective: «» Labs pending «» HIV negative «» Other lab results within normal limits «» Abnormal lab results; action: «» Assessment / Plan: Continue HIV PrEP «» daily «» on demand «» HIV PrEP prescription submitted to Pharmacy «» Pick up reviewed (4-5d at SPH / within 30d / send to local pharmacy / urgent) «» Client declined refill PrEP lab work requisition «» Client has current standing requisition «» Requisition updated; current address/email confirmed «» Tasked for mail out «» Emailed to client «» Faxed to lab Additional STI testing reviewed «» TP/GC/CT testing with labs, HCV within last 12 months «» GC/CT swab kit arranged (task or pick-up) «» declined additional STI screening Doxycycline B-STI Prophylaxis discussed «» «» Doxycycline B-STI Prophylaxis prescription submitted «» Doxycycline B-STI Prophylaxis declined «» Discussion Deferred Vaccination reviewed «» vaccines up to date (add to diagnosis list) «» vaccines recommended: «» HAV; «» HBV; «» HPV; «» Mpox «» Client refused vaccines (Add FOC task) Next Follow up appointment in 3 months with: «» HIM NP/MD (every 6-12 months) Provider: «» «» HIM Nursing «» Client’s GP (offer referral pack if relevant) Notes: «» |
| PREPI | PrEP initial visit | PrEP Initial Visit Patient presents for consideration of initiation of PrEP vs HIV. Type of visit: «in-person, phone or Zoom» - Allergies: «» - Medications/supplements: «» - Significant Medical Hx: «» - Family Physician: «» - Prior PrEP: «» - Recreational substance use: «» - HIRI-MSM Score: «» - Other risk factors: «» Prior recurrent NPEP use: «» Prior rectal STI: «» Prior syphilis: «» Known HIV+ partner where VL not <200 copies/ml: «» Other than above: «» - HAV immune status: «» - HBV immune status (if chronic carrier, discuss impact of PrEP): «» - HPV vaccination status: «» - Mpox vaccination status: «» - Baseline lab results: «» - HIV confirmed negative (latest test date): «» - Renal function (latest test date & N or abN): «» PrEP discussed including: - One tablet consisting of 2 antiretroviral medications, tenofovir & emtricitabine - No protection against other STIs (risk reduction counselled & condom use) - Efficacy and adherence - 7 consecutive days to reach protective levels (possibly up to 20 for vaginal sex) - Discussed reporting any seroconversion symptoms - Possible side effects on initiation: most people have none: GI, headache, dizziness, fatigue Rare: allergic rxn, renal, bone density Monitoring: baseline, Kidney fun and HIV after ~2wks on PrEP, & every 90day Bone density: decrease, stabilizes, returns to baseline post-PrEP - Ensure best bone health with: wt-bearing exercise, calcium and vit D 1000-2000IU/day - When stopping PrEP: Continue PrEP at least 48 hours after a high risk encounter (IPERGAY protocol). Some groups recommend continuing up to 28 days. - For women: assess for pregnancy A/P: - Start tenofovir disoproxil fumarate/emtricitabine - Given 1 mth lab requisition (Cr, GFR, Urine ACR, HIV) - Discussed access to Provincial Program including: Need for valid BC MSP Pick up site – St Paul’s Hospital Outpatient Pharmacy Room 163 Burrard Building - Enrolment Rx Request form faxed to BC-CfE Drug Treatment Program - Explained confirmation of coverage will be faxed to us in a few days. Pharmacy requests 3 business days from that date to package the medication. We will inform patient of confirmation if possible. If the patient does not hear from us, they are to go to pick up the medications in 7 days (8+ if over a long weekend). - Appointment made for 1-month visit: «» Type of visit: «in-person, phone or Zoom» Added to Memora: «» |
| PREPMD | PrEP bloodwork for MD to review | PrEP bloodwork for MD to review; Tasked to CPS-Physician |
| PREPRE | PrEP restart visit | PrEP Re-Start Visit - Patient in for PrEP Re-Start - Type of visit: «in-person, phone or Zoom» - No reported issues/adverse events in the past; last taken PreP on «», and stopped because «». - No changes in medical hx/meds/allergies - No signs/symptoms of acute HIV infection in past 4 weeks - Bloodwork reviewed: «no issues» A/P: - Restart with tenofovir disoproxil fumarate/emtricitabine – mitte 90 tabs - Swabs done for CT/GC NAT throat + rectum - Adherence reinforced, as well as importance of bone protection measures and condom use for prevention of other STIs. - Gave 3-monthly standing order lab requisition: «» To be done a week prior to each visit - Enrolment Rx Request form faxed to BC-CfE Drug Treatment Program - Reminded the patient that confirmation of coverage will be faxed to us in a few days; the pharmacy requests 3 business days from that date to package the medication. We will inform patient of confirmation if possible. If the patient does not hear from us, they are to go to pick up the medications in 7 days (8+ if over a long weekend). - Appointment made for next 3-month visit: «» Type of visit: «in-person, phone or Zoom» Added to Memora: «» |
| PREPREF | PrEP Referral Assessment (calls PREPREFTEXT) | |
| PREPREFTEXT | PrEP Referral Assessment (TEXT ONLY) | PrEP Referral Assessment *Use F4 to tab through the «»* Sex Assigned at Birth: «» Male, «» Female Gender Identity: «» *enter in “Gender Identity” tab in Encounter Note* Ethnicity: «» HIRI-MSM Risk Index Calculator (Score > 10 Suggests HIV Incidence > 2% in Vancouver) Question Response Value Score 1. Age in years? 18-28 yrs ---- 8 29-40 yrs ---- 5 41-48 yrs ---- 2 ≥ 49 yrs ---- 0 «» 2. # Male partners in past 6 months? > 10 partners ---- 7 6-10 partners ---- 4 0-5 partners ---- 0 «» 3. # HIV-positive male partners in past 6 months? > 1 partner ---- 8 1 partner ---- 4 < 1 partner ---- 0 «» 4. # TIMES having unprotected receptive anal sex in past 6 months? ≥ 1 time ---- 10 0 times ---- 0 «» 5. # TIMES having unprotected insertive anal sex with an HIV (+) partner in past 6 months > 5 times ---- 6 0-4 times ---- 0 «» 6. Methamphetamine use in past 6 months? Yes ---- 5 No ---- 0 «» 7. Poppers (Nitrate Insuflation) in past 6 months? Yes ---- 3 No ---- 0 «» Total HIRI Score: «» *Enter HIRI as a manual measure in EMR “Results”* Co-Morbidities (put an x by all that apply) Chronic Active Hepatitis B «» Hepatitis C «» Chronic Renal Impairment/CKD «» Diabetes «» Hypertension «» Depression/Anxiety «» Osteoporosis/Low Bone Mass «» Other Significant Issues? PMHx: «» Describe: «» Current Medications: «» ** Add to EMR Problem List, Usual Prescriptions** Medication interactions with Truvada?: «» Allergies: «» ** Add to EMR Adverse Reaction box** HIV Risk (put an x by all that apply) MSM: «» HIRI >10 «» Prior Rectal STI and Syphilis «» Prior NPEP «» PrEP Referral Plan Referral to: «» Client’s existing Primary Care Provider (GP/NP) Give doctor referral package to client «» «» Youth clinic (under 25yrs) «» Student health (UBC, SFU, Langara) «» Telus health (especially outside of VCH) «» GoFreddie.com (if has extended health insurance) «» Private pay (no MSP and has means to pay) «» HIM Clinic (no viable alternative to access PrEP) «» RN «» NP/MD **clients with HiRi >25, co-morbidities, and/or Truvada med interactions only** Referral Checklist (for HIM PrEP starts only) «» Active MSP coverage confirmed through HCIM registry «» NO MSP PrEP **HIRI MUST BE OVER 25 FOR NO MSP PrEP** «» Confirm correct address in EMR «» Date of Prep Start appt: «» PrEP info package given «» Baseline requisition given (Advised labs to be done within 15 days of Prep start appt) «» Advised to abstain from unprotected sex until on PrEP to avoid delay of PrEP start «» Appointment appropriate length (eg. 60 minutes if translation needed) |
| PREPRN | HIV Pre-Exposure Prophylaxis | HIV Pre-Exposure Prophylaxis (PrEP) Assessment Form Type of encounter 1. Routine STI screening visit «» HIRI-MSM > 10 «» HIV+ partner not on ART «» Self-reported NPEP use «» PrEP self-referral 2. STI diagnosis «» Rectal GC or chlamydia «» Syphilis Action 1. PrEP recommended «» Yes «» No 2. Client accepted referral «» Yes «» No 3. Provide client with appropriate PrEP information «» PrEP Fact Sheet (in PrEP package) «» Link to HiM PrEP website - http://www.getpreped.ca/ 4. Making the Referral: a. If referring to PrEP Service at Bute or HiM Clinic: «» Complete collection of PrEP Baseline Laboratory work. «» For Bute bookings: «» For HiM clinic: for physician appointment bookings, contact MOA at 604 714 6269 or Fax to Dr Hull’s office 604 806 8683 b. If referring to client’s GP in community: «» Fax PrEP Recommendation Letter to identified provider. «» If required, facilitate HIV/STI testing for client. 5. Documentation «» Record HIRI-MSM in patient record with date. |
| PREV | Previously Known Syphilis | Previously Known Syphilis |
| PREVENT | Open Preventive Health Form | |
| PREVR | Previously Reactive | Previously Reactive |
| PRFC | PSS (Personalized Support & Stabilization) RH – First Contact | |
| PRO | Peer: Outreach | |
| PROC | PSS (Personalized Support & Stabilization) RH – Ongoing Care | |
| PS | Psychiatry Note | |
| PS1 | Template - Pain Visual Analog Scale (Color) (AccelEMR) |  |
| PS2 | Template - Pain Visual Analog Scale (B&W) (AccelEMR) |  |
| PSA | Psychosocial Assessment | |
| PSDC | PSS (Personalized Support & Stabilization) SPH – Discharge Note | |
| PSF | Template - Pain Faces Scale (AccelEMR) |  |
| PSFC | PSS (Personalized Support & Stabilization) SPH – First Contact | |
| PSOC | PSS (Personalized Support & Stabilization) SPH – Ongoing Care | |
| PSR | Psychosocial Rehab Note | |
| PSSIV | PSS - Initial Patient Visit | NP Patient Initial Visit BACKGROUND Patient is an «» year old «» patient who lives «». Recently discharged from LGH after admission from «» to «». Presented to emergency department with «». Admission was complicated by «». Historically patient had recent hospital admissions for: • «Date» • «Date» Patient was discharged home «» to the Patient Stabilization and Support Team where «» will receive ongoing rehabilitation in their home. MRP on Discharge: GP: Specialists: Pharmacy: Allergies: Code Status: SUBJECTIVE: 1. General 2. 3. Positive Review of Systems: ADLs: «» Dressing: «» Eating: «» Ambulating: «» Toileting: «» Hygiene: «» IADLs: Meal prep/cooking accidents: «» Cleaning/laundry: «» Shopping: «» Transportation: «» Med management: «» Finances: «» Social History: Occupation: «» Exercise: «» Travel: «» Family: «» POA/REP: «» Community Supports: Known to community health Medical History Care Connect, PARIS and Pharmanet reviewed Consent to discuss care with family and other health care providers received from patient PMHx: «» Past Surgical History: «» Immunizations: «» Substance Abuse: «» Smoking: «» ETOH: «» Illicit: «» Medications: «» Recent labs: «» Recent Investigations: «» MOCA/MMSE/PHq9: «» Physical Exam VS: GENERAL: Patient found «». Affect is variable and appropriate; dress is fitting for weather and occasion. Grooming and hygiene are neat and clean. Home is tidy and free of clutter. Patient is able to follow commands throughout history and examination. Orientated to person, place, time, and situation. NEURO: Facial structures are symmetrical at rest and while smiling, no drooping or asymmetry noted. PERRLA, 3mm. Gait is «». No tremors noted. Upper and Lower extremities muscle strength is strong and equal bilaterally. CVS: The rate is regular with no irregular beats. S1 and S2 are present without splitting, rubs or murmurs. No S3 or S4 auscultated. Radial, DP/PT pulses are +1 and equal bilaterally. Skin to lower extremities is warm and pink to touch. Bilateral capillary refill to great toe brisk. No edema present. RESP: Respirations are regular and non-labored. No use of accessory muscles noted. Vesicular sounds are auscultated throughout all lung fields both anteriorly and posteriorly. No unusual location of breath sounds, crackles, wheezes, or rubs. No bronchophony noted. SKIN: Skin is without any visible rashes, lesions, or masses. Nail beds are pink with brisk capillary refill. No clubbing noted. ASSESSMENT/PLAN 1. XXX • Diagnosis discussed with patient, counselled on treatment plan, prognosis, and outcomes • Teaching provided regarding • Discussed • Reassured • Advised • Suggested • Red flags discussed and patient aware to call 911 if occur • Patient aware to seek medical attention if • RX: • Counselled regarding potential medication adverse effects, side effects, and length of treatment • Follow up with patient 2. XXX • Diagnosis discussed with patient, counselled on treatment plan, prognosis, and outcomes • Teaching provided regarding • Discussed • Reassured • Advised • Suggested • Red flags discussed and patient aware to call 911 if occur • Patient aware to seek medical attention if • RX: • Counselled regarding potential medication adverse effects, side effects, and length of treatment • Follow up with patient 3. XXX • Diagnosis discussed with patient, counselled on treatment plan, prognosis, and outcomes • Teaching provided regarding • Discussed • Reassured • Advised 4. XXX • Diagnosis discussed with patient, counselled on treatment plan, prognosis, and outcomes • Teaching provided regarding • Discussed • Reassured • Advised 5. XXX • Diagnosis discussed with patient, counselled on treatment plan, prognosis, and outcomes • Teaching provided regarding • Discussed • Reassured • Advised 6. DISPOSITION • Letter sent to GP Dr. to assess level of involvement during PSS 8 week program. Awaiting reply. • NP will continue to follow patient in community on an as needed or urgent basis depending on GP involvement. • Patient and family given PSS contact information. • Follow up with patient on |
| PSW | Peer Support Worker Note | |
| PSWAL | PSW Activity Log | |
| PSWALTEXT | PSW Activity Log (TEXT ONLY) | Client Goal: «» Status of Goal (New, In progress, Completed):«» Frequency of Client/PSW Meetings: «» Activity Details - briefly describe what happened at this PSW Meeting:«» Subjective - What the client told you at this meeting:«» Objective - What the PSW observed:«» Plan - Plan or objectives for the next meeting and what the client plans to do before the next meeting to meet their goal:«» |
| PSY | Psychiatry Note | |
| PT | Template - Pregnancy Test (AccelEMR) | Pregnancy Test Preg Test: «negative» «positive» (Recorded by: «») |
| PTCD | Pacifica Treatment Centre – Discharge | |
| PTCF | Pacifica Treatment Centre - Follow Up | |
| PTCI | Pacifica Treatment Centre – Intake Assessment | |
| PVDC | PSS (Personalized Support & Stabilization) VGH – Discharge Note | |
| PVFC | PSS (Personalized Support & Stabilization) VGH – First Contact | |
| PVOC | PSS (Personalized Support & Stabilization) VGH – Ongoing Care | |
| PW | precepiptated | precepiptated withdrawal |
| QT | Potential for QT prolongation | Potential for QT prolongation due to drug interaction and/or patient risk factors I have reviewed the medication and medical records available to me for your patient «Letter.Patient.FullName» and would like to notify you that the following are identified risk factors for QT prolongation. Medications: 1. «» started on «» 2. «» started on «» 3. «» started on «» Patient factors (Delete those that do not apply): Documented prolonged QT «» ms on «» Heart disease (CHF, MI) «» Advanced age «» yrs «Female sex» «Electrolyte imbalance (hypokalemia, hypomagnesemia, hypocalcemia)» «Impaired hepatic drug metabolism» «Bradycardia» «Treatment with diuretics» Action required (Delete those that do not apply): o Please acknowledge receipt of this notification and notify our pharmacy of any medication changes desired by «» We will follow-up by phone if we do not receive a response from you. o No response required at this time. Please retain this notice or make note of the information in your patient files. |
| RA2 | PSP-MSK (SOAP) - RA - Followup Visit (calls RA2TEXT) | |
| RA2TEXT | PSP-MSK (SOAP) - RA - Followup Visit (TEXT ONLY) | Rheumatoid Arthritis - Follow-up Visit SUBJECTIVE: «Tab using F4» [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] Overall improvment: Better [ «» ], The same [ «» ], Worse [ «» ] Pain - avg last month: «» /10 (10=Very Severe) How much pain have you had in the last month, on average, from your arthritis? Pain Control: Satisfied [ «» ], Unsatisfied [ «» ] Frequency: «» Interferance with sleep: «» Morning Stiffness: Duratation «» min (over 30 min significant for inflammation) Fatigue: «» /10 (10=Very Severe) Functional Limitations: Mobility: «»; Self Care: «» Difficulties: Work: «»; Leisure: «»; Other: «» Global Disease Activity: «»/10 (0=Very Well, 10=Very Poor) Considering all of the ways your arthritis has affected you, how do you feel your arthritis is today? Medication - use/toxicity: «» Other Info: «» OBJECTIVE: Number of tender joints: [ «» ] Number of swollen joints: [ «» ] Global Disease Act (MD): «» /10 (0=None, 10=Very Active) What is your assessment of the patient’s current disease activity? Labs: Last CRP: «Letter.Patient.Macro.LATESTCRP» Calculate: CDAI [ «» ], or SDAI [ «» ] - Click on Prov Ref: OA/RA Algorithm and go to pg 31 ASSESSMENT: Disease Activity: Remission [ «» ], Low [ «» ], Moderate [ «» ], High [ «» ] Assess comorbidities: «» (RA is a risk factor for CVD, infection, OA, osteoporosis and depression) If considering NSAID, to review risk factors, nrf«Tab using F4 then Type"\" to insert dropdown» PLAN: Imaging: «» (Yearly of hands, feet and symptomatic joints when disease is active) Medication: Acetaminophen [ «» ], NSAID [ «» ], Other [ «» ] (Treat with DMARDs E.A.R.L.Y.) Referrals: «» (Rheum q6-12/12) Education: Email OA/RA - Chronic Pain Toolkit (14 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Self-management: Email OS/RA - Self Management file (19 pgs) [ «» ] - Click Email Patient icon in Main Toolbar Followup: «Letter.Patient.Next Appointment.Date»«» (q1-3/12 when disease active and q3-6/12 when in remission) Other: «» |
| RAAB | RAAC Behavior (calls RAABTEXT) | |
| RAABTEXT | RAAC Behavior (TEXT ONLY) | Description of incident: «» Action taken: «» Followup (Boundary discussion, Task to CNL for BSP, PSLS): «» Recommendation for team: «» |
| RACE | Template - Rapid Access to Consultative Expertise (AccelEMR) | Rapid Access to Consultative Expertise (RACE) - Telephone Consutation Timely guidance and advice regarding assessment, management and treatment Calls returned within 2 hours and commonly within an hour Monday to Friday from 8am-5pm Phone number: 604-696-2131 (or toll-free 1-877-696-2131). Extensions: Chronic Pain-0; Nephrology-1; Cardiology-2; GI-3; Respirology-4; Endocrinology-5; Internal Medicine-6; Psychiatry-7; Geriatrics-8; Rheumatology (>18yo)-9 If no reply within hours, call 604-682-2344 ext 66522 Billing Code: 14018 General Practice urgent telephone conference with a specialists (Go to Prov Ref: RACE for more details) |
| RAKT | RAAC Rapid Kadian Titration (calls RAKTTEXT) | |
| RAKTTEXT | RAAC Rapid Kadian Titration (TEXT ONLY) | Rapid Kadian Titration performed in clinic. See Clinical assessment flowsheet, MAR, and PPO in Documents under "RAAC Rapid Kadian Titration". |
| RANA | RAAC Nursing Follow-up assessment (calls RANATEXT) | |
| RANATEXT | RAAC Nursing Follow-up assessment (TEXT ONLY) | Reason for visit: • «» Discharge Planning: • «» Previous prescriptions (Medinet Checked/ Pharmacy called to verify today’s dose) • Last dose «» • Missed doses? «» Current Substance Use: • Opioids: «» • Stimulants: «» • Sedatives: «» • Alcohol: «» Harm Reduction: • Recent ODs: «» • THN: «» Social • Housing: «» • Pharmacy: «» • Needs to see Social work: «» Clinical Assessment: (ie COWS, CIWA, PAWS ect.) «» Urine Drug Screen: «» |
| RANI | RAAC Nursing Intake Typing Template (calls RANITEXT) | |
| RANITEXT | RAAC Nursing Intake Typing Template (TEXT ONLY) | Collateral Review (Care Connect, Alerts, Pharmanet, referral source/ reason): • «» Chief Concern on intake: • «» Discharge Planning: • «» Contacts (Alias, Areas frequented, alt contacts) • «» Previous prescriptions (Medinet Checked/ Pharmacy called to verify today’s dose) • Last dose «» • Missed doses? «» Current Substance Use: • Opioids: «» • Stimulants: «» • Sedatives: «» • Alcohol: «» Harm Reduction: • Recent ODs: «» • THN: «» Social • Housing: «» • Pharmacy: «» • Needs to see Social work: «» Consent: • «» Clinical Assessment: (ie COWS, CIWA, PAWS ect.) «» Urine Drug Screen: «» |
| RATP | VCT-COVID Positive (calls RATPTEXT) | |
| RATPTEXT | VCT-COVID Positive (TEXT ONLY) | Client tested positive on COVID-19 rapid antigen test on (date: «») at (location: «»). Vaccination status: «» Symptom Onset Date (SOD): «» Earliest Clearance Date (ECD): «» Plan: «» |
| RBR1 | Template, Visit - Rourke Baby Record: 0-1 month (call RBR1TEXT) | |
| RBR1TEXT | Template, Visit - Rourke Baby Record: 0-1 month (TEXT ONLY) | ROURKE BABY RECORD - 0-1 MONTH (Current Age: «Letter.Patient.Age») Growth Length «» Weight «» Head Circumference «» Subjective: Pregnancy/Birth Info: «» Family History: Add to Social/Risk Problem "Family Hx" Caregiver Concerns: «» Nutrition1 : [ «» ] Breastfeeding (exclusive)1; [ «» ] Vitamin D 10 ug = 400IU/day; [ «» ] Formula Feeding (iron-fortified); [ «» ] Stool pattern and urine output Education & Advice: Instructions - Enter [ n ] if discussed and no concerns (i.e. normal, or [ x ] if concerns) · Injury Prevention: [ «» ] Car seat (infant)1 [ «» ] Sleep position/co-sleeping1 [ «» ] Firearm safety/removal1 [ «» ] Carbon monoxide/smoke detectors1 [ «» ] Choking/safe toys1 [ «» ] Hot water <49° C 1 [ «» ] Crib Safety1 · Behavior/family issues:[ «» ] Sleeping/crying2 [ «» ] Soothability/responsiveness [ «» ] Assess home visit need 2 [ «» ] Siblings [ «» ] Parenting/bonding [ «» ] Parental fatigue/postpartum depression2 [ «» ] Family conflict/stress · Other Issues: [ «» ] Second-hand smoke1 [ «» ] Counsel on pacifier use1 [ «» ] No OTC cough/cold med'n 1 [ «» ] Inquiry on complementary/alternative medicine [ «» ] Fever advice/thermometers1 [ «» ] Temperature control and overdressing1 [ «» ] Sun exposure/sunscreens/insect repellant1 Development2 : Instructions - Enter [ n ] if discussed and no concerns (i.e. normal, or [ x ] if concerns) · 2 Weeks: [ «» ] Sucks well on nipple Other caregiver concerns: [ «» ] · 1 Month: [ «» ] Sucks well on nipple [ «» ] Calms when comforted [ «» ] Focuses gaze [ «» ] Startles to loud or sudden noise Other caregiver concerns: [ «» ] Objective: Instructions - Enter "n" if normal or "x" if abnormal; Evidence-based screening for specific conditions is bold, but an appropriate age-specific focused physical examination is recommended at each visit. Skin (jaundice/dry) «» Fontanelles1 «» Eyes (red reflex)1 «» Corneal light reflex1 «» Ears/Hearing «» Heart/Lungs «» Umbilicus «» Femoral Pulses «» Hips1 «» Muscle tone1 «» Testicles «» Male urinary/foreskin «» Assessment/Plan: Immunizations: [ «» ] If HBsAg-positive parent/sibling, give Hep B Vaccine [ «» ] «» Next Appointment: «Letter.Patient.Next Appointment.Date» «» Strength of recommendation based on literature review using the classification of the Canadian taskforce on Preventative Health Care: Bold type - Good evidence, Italic - Fair evidence, Plain - Consensus 1 See Provider Reference: General Info 2 See Provider Reference: Healthy Child Development Disclaimer: Given the constantly evolving nature of evidence and changing recommendations, the Rourke Baby Record is meant to be used as a guide only. |
| RBR2 | Template, Visit-Rourke Baby Record: 2-6 months (calls RBR2TEXT) | |
| RBR2TEXT | Template, Visit - Rourke Baby Record: 2-6 months (TEXT ONLY) | ROURKE BABY RECORD - 2-6 MONTHS (Current Age: «Letter.Patient.Age») Growth Length «» Weight «» Head Circumference «» Subjective: Family History: Add to Social/Risk Problem "Family Hx" Caregiver Concerns: « » Nutrition1 · 2 Months: [ «» ] Breastfeeding (exclusive)1; [ «» ] Vitamin D 10 ug = 400IU/day; [ «» ] Formula Feeding (iron-fortified)1 · 6 Months: [ «» ] Breastfeeding1- introduce solids [ «» ] Vitamin D 10 ug = 400IU/day; [ «» ] Formula Feeding (iron-fortified)1 [ «» ] Choking/safe food1 [ «» ] Avoid sweetened juices [ «» ] Fruits and vegetables to follow [ «» ] No bottles in bed [ «» ] No egg white, nuts, or honey [ «» ] Iron containing foods (cereals, meat, egg yolk, tofu) Education & Advice: Instructions - Enter [ n ] if discussed and no concerns (i.e. normal, or [ x ] if concerns) · Injury Prevention: [ «» ] Car seat (infant)1 [ «» ] Sleep position/co-sleeping1 [ «» ] Poisons1/Electrical plugs/cords [ «» ] Firearm safety/removal1 [ «» ] Choking/safe toys1 [ «» ] Hot water <49° C 1 [ «» ] Crib Safety1 [ «» ] Carbon monoxide/smoke detectors1 · Behavior/family issues:[ «» ] Soothability/responsiveness [ «» ] Sleeping/crying/Night waking2 [ «» ] Assess home visit need 2 [ «» ] Childcare 2/ return to work [ «» ] Parenting/bonding [ «» ] Parental fatigue/postpartum depression2 [ «» ] Family conflict/stress [ «» ] Siblings · Other Issues: [ «» ] Second-hand smoke1 [ «» ] Counsel on pacifier use1 [ «» ] No OTC cough/cold med'n 1 [ «» ] Inquiry on complementary/alternative medicine [ «» ] Fever advice/thermometers1 [ «» ] Temperature control and overdressing1 [ «» ] Encourage reading2 [ «» ] Sun exposure/sunscreens/insect repellant1 [ «» ] Teething/Dental/Fluoride1 [ «» ] Pesticide exposure1 Development2 : Instructions - Enter [ n ] if discussed and no concerns (i.e. normal, or [ x ] if concerns) · 2 Months [ «» ] Follows movement with eyes [ «» ] Coos - throaty gurgling sounds [ «» ] Lifts head up while lying on tummy [ «» ] Can be comforted & calmed by touching/rocking [ «» ] Smiles responsively [ «» ] Sequences 2 or more sucks before swallowing/breathing Other caregiver concerns: [ «» ] · 4 Months [ «» ] Eyes track a moving toy/person [ «» ] Responds to people with excitement [ «» ] Holds head steady when supported in sitting position [ «» ] Laughs/smiles responsively [ «» ] Holds an object briefly in place in hand Other caregiver concerns: [ «» ] · 6 Months [ «» ] Turns head towards sounds [ «» ] Make sounds when talked to [ «» ] Vocalizes pleasure & displeasure [ «» ] Rolls from back to side [ «» ] Sits with support [ «» ] Reaches/grasps objects Other caregiver concerns: [ «» ] Objective: Instructions - Enter "n" if normal or "x" if abnormal; Evidence-based screening for specific conditions is bold, but an appropriate age-specific focused physical examination is recommended at each visit. Fontanelles1 «» Eyes (red reflex)1 «» Corneal light reflex1 «» Hearing inquiry «» Heart «» Hips1 «» Muscle tone1 «» Assessment/Plan: Immunizations: [ «» ] If HBsAg-positive parent/sibling, give Hep B Vaccine [ «» ] «» Next Appointment: «Letter.Patient.Next Appointment.Date» «» Strength of recommendation based on literature review using the classification of the Canadian taskforce on Preventative Health Care: Bold type - Good evidence, Italic - Fair evidence, Plain - Consensus 1 See Provider Reference: General Info 2 See Provider Reference: Healthy Child Development Disclaimer: Given the constantly evolving nature of evidence and changing recommendations, the Rourke Baby Record is meant to be used as a guide only. |
| RBR3 | Template, Visit-Rourke Baby Record: 9-15 months(calls RBR3TEXT) | |
| RBR3TEXT | Template, Visit - Rourke Baby Record: 9-15 months (TEXT ONLY) | ROURKE BABY RECORD - 9-15 MONTHS (Current Age: «Letter.Patient.Age») Growth Length «» Weight «» Head Circumference «» Subjective: Family History: Add to Social/Risk Problem "Family Hx" Caregiver Concerns: «» Nutrition1 · 9 Months: [ «» ] Breastfeeding1 [ «» ] Vitamin D 10 ug = 400IU/day [ «» ] Formula Feeding (iron-fortified)1 [ «» ] Encourage cup instead of bottle [ «» ] Choking/safe food1 [ «» ] Avoid sweetened juices [ «» ] Fruits and vegetables to follow [ «» ] Cow's milk products (ypgurt, cheese, homo milk) [ «» ] No bottles in bed [ «» ] No egg white, nuts, or honey [ «» ] Cereal, meat/alternatives, fruits, vegetables · 12-15 Months [ «» ] Breastfeeding1 [ «» ] Homogenized milk (16-24 oz/day) [ «» ] Appetite reduced [ «» ] Promote cup instead of bottle [ «» ] Choking/safe food1 [ «» ]Avoid sweetened juices [ «» ] Inquire re: vegetarian diets1 Education & Advice: Instructions - Enter [ n ] if discussed and no concerns (i.e. normal, or [ x ] if concerns) · Injury Prevention: [ «» ] Car seat (infant)1 [ «» ] Falls/stairs/no walkers 1 [ «» ] Poisons1 [ «» ] Firearm safety/removal1 [ «» ] Choking/safe toys1 [ «» ] Hot water <49° C 1 [ «» ] Electrical plugs/cords [ «» ] Carbon monoxide/smoke detectors1 · Behavior/family issues:[ «» ] Soothability/responsiveness [ «» ] Sleeping/crying/Night waking2 [ «» ] Assess home visit need 2 [ «» ] Childcare 2/ return to work [ «» ] Parenting2 [ «» ] Parental fatigue/postpartum depression2 [ «» ] Family conflict/stress [ «» ] Siblings · Other Issues: [ «» ] Second-hand smoke1 [ «» ] Counsel on pacifier use1 [ «» ] No OTC cough/cold med'n1 [ «» ] Inquiry on complementary/alternative medicine [ «» ] Fever advice/thermometers1 [ «» ] Active living/ screen time1 [ «» ] Encourage reading2 [ «» ] Sun exposure/sunscreens/insect repellant1 [ «» ] Teething/Dental/Fluoride1 [ «» ] Pesticide exposure1 [ «» ] Footware1 [ «» ] Serum Lead if at risk1 Development2 : Instructions - Enter [ n ] if discussed and no concerns (i.e. normal, or [ x ] if concerns) · 9 Months [ «» ] Looks for an object seen hidden [ «» ] Responds differently to different people [ «» ] Babbles a series of different sounds [ «» ] Opposes thumbs and fingers when grasps objects [ «» ] Sits without support [ «» ] Stands with support when helped to standing Other caregiver concerns: [ «» ] [ «» ] Plays social games (eg. peek-a-boo) [ «» ] Cries or shouts for attention [ «» ] Makes gestures/sounds to get attention/help · 12-13 Months [ «» ] Responds to own name [ «» ] Says >3 words (do not have to be clear) [ «» ] Holds Crawls or "bum" shuffles" [ «» ] Makes at least 1 consonant/vowel combination [ «» ] Pulls to stand/walks holding on [ «» ] Responds to simple requests eg. Where is the ball? [ «» ] Follows your gaze to jointly reference an object [ «» ] Shows distress when seperated from caregiver Other caregiver concerns: [ «» ] · 15 Months [ «» ] Says 5 or more words [ «» ] Picks up and eats finger foods [ «» ] Walk sideways holding onto furniture [ «» ] Shows fear of strange people/places [ «» ] Tries to squat to pick up toys from floor [ «» ] Crawls up a few stairs/steps Other caregiver concerns: [ «» ] Objective: IInstructions - Enter "n" if normal or "x" if abnormal; Evidence-based screening for specific conditions is bold, but an appropriate age-specific focused physical examination is recommended at each visit. Anterior fontanelle1 «» Eyes (red reflex)1 «» Corneal light reflex1 «» Hearing inquiry «» Hips1 «» Snoring/tonsil size1 «» Teeth «» Assessment/Plan: Immunizations: [ «» ] If HBsAg-positive parent/sibling, give Hep B Vaccine [ «» ] «» Next Appointment: «Letter.Patient.Next Appointment.Date» «» Strength of recommendation based on literature review using the classification of the Canadian taskforce on Preventative Health Care: Bold type - Good evidence, Italic - Fair evidence, Plain - Consensus 1 See Provider Reference: General Info 2 See Provider Reference: Healthy Child Development Disclaimer: Given the constantly evolving nature of evidence and changing recommendations, the Rourke Baby Record is meant to be used as a guide only. |
| RBR4 | Rourke Baby Record: 18 mos - 5 yrs (calls RBR4TEXT) | |
| RBR4TEXT | Rourke Baby Record: 18 mos - 5 yrs (TEXT ONLY) | RBR4 – Template, Visit - Rourke Baby Record:18 months-5yr ROURKE BABY RECORD - 18 Months to 5 Years (Current Age: «Letter.Patient.Age») Subjective: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] Family History: Add to Clinical Details or Social/Risk Problem "Family Hx" Caregiver Concerns: «» Nutrition1 : · 18 Months: [ «» ] Breastfeeding1 [ «» ] Homogenized milk (16-24 oz/day) [ «» ] Avoid sweetened juices [ «» ] No bottles · 2-5 Years: [ «» ] 1%-2% milk (~16oz/day1) [ «» ] Gradual transition to lower fat diet1 [ «» ] Canada's Food Guide1 [ «» ] Inquire re: vegetarian diets1 Education & Advice: Instructions - Enter "n" if discussed and no concerns (i.e. normal, or"x" if concerns 18 Months: · Injury Prevention: [ «» ] Car seat (child)1 [ «» ] Choking/safe toys1 [ «» ] Bath safety 1 · Behavior & family issues: [ «» ] Discipline/Parenting skills program2 [ «» ] Parental fatigue/stress/depression2 [ «» ] High risk children2 [ «» ] Parent/child interaction · Other Issues: [ «» ] Socializing/peer play opportunities1 [ «» ] Toilet learning2 [ «» ] Encourage reading2 [ «» ] Dental care/Dentist1 [ «» ] Wean from pacifier2 2-5 Years: · Injury Prevention: [ «» ] Car seat (child/booster)1 [ «» ] Bike helmets1 [ «» ] Firearm safety/removal1 [ «» ] Matches [ «» ] Water safety1 [ «» ] Carbon monoxide/smoke detectors1 · Behavior/family issues: [ «» ] Discipline/Parenting skills program2 [ «» ] High risk children2 [ «» ] Parent/child interaction [ «» ] Parental fatigue/stress/depression2 [ «» ] Family conflict/stress [ «» ] Siblings [ «» ] Assess child care/preschool needs/school readiness2 [ «» ] Second-hand smoke1 [ «» ] No OTC cough/cold medn 1 [ «» ] Complementary/alternative medicine [ «» ] Active living/ screen time1 [ «» ] Encourage reading2 [ «» ] No pacifiers1 [ «» ] Dental cleaning/Fluoride/Dentist1 [ «» ] Toilet learning1 [ «» ] Socializing opportunities Other Issues: [ «» ] Sun exposure/sunscreens/insect repellant1 [ «» ] Pesticide exposure1 [ «» ] Serum Lead if at risk1 Development2 : Instructions - Enter "n" if discussed and no concerns (i.e. normal, or"x" if concerns · 18 Months: [ «» ] Child's behavior is usually manageable [ «» ] Interested in other children [ «» ] Usually easy to soothe [ «» ] Comes for comfort when distressed [ «» ] Points to several differnt body parts [ «» ] Responds when name is called [ «» ] Tries to get your attention by showing you something [ «» ] Points to what he/she wants [ «» ] Looks for toy when asked [ «» ] Imitates speech sounds and gestures [ «» ] Says >20 words, don't have to be clear [ «» ] Produces 4 consonants, eg, BDGNH [ «» ] Walks alone [ «» ] Feeds self with spoon with little spilling [ «» ] Removes hat/sock without help Other caregiver concerns: [ «» ] · 2 Years: [ «» ] Combines >2 words [ «» ] Understands 1&2 step directions [ «» ] Walks backward 2 steps without support [ «» ] Puts objects into small container [ «» ] Continued to develop new skills [ «» ] Uses toys for pretend play [ «» ] Tries to run Other caregiver concerns: [ «» ] · 3 Years: [ «» ] Understands 2&3 step directions [ «» ] Asks and answers lots of questions [ «» ] Walks up stairs using handrail [ «» ] Plays make-believe games with actions & words [ «» ] Turns pages 1 at a time [ «» ] Listens to music or stories for 5-10 min. [ «» ] Shares some of the time [ «» ] Twists lids off jars or turns knobs Other caregiver concerns: [ «» ] · 4 Years: [ «» ] Understands 3 part directions [ «» ] Uses sentences with >5 words [ «» ] Walks up stairs up/down stairs [ «» ] Undoes buttons/zippers [ «» ] Tries to comfort someone who is upset Other caregiver concerns: [ «» ] · 5 Years: [ «» ] Counts out loud or on fingers [ «» ] Throws and catches a ball [ «» ] Speaks clearly in adult-like sentences most of the time [ «» ] Hops on 1 foot several times [ «» ] Dresses & undresses with little help [ «» ] Cooperates with adult requests most of the time [ «» ] Retells the sequence of a story [ «» ] Separates easily from parent/caregiver Other caregiver concerns: [ «» ] Objective: Instructions - Enter "n" if normal or "x" if abnormal; Evidence-based screening for specific conditions is bold, but an appropriate age-specific focused physical examination is recommended at each visit. Blood pressure (>2yrs) «» Anterior fontanelle closed1 «» Eyes (red reflex/visual acuity)1 «» Corneal light reflex1 «» Hearing inquiry «» Hips1 «» Snoring/tonsil size1 «» Teeth «» Assessment/Plan: Record vaccines on Provider Reference Guide V [ «» ] «» Next Appointment: «Letter.Patient.Next Appointment.Date» «» Strength of recommendation based on literature review using the classification of the Canadian taskforce on Preventative Health Care: Bold type - Good evidence, Italic - Fair evidence, Plain - Consensus 1 See Provider Reference: General Info 2 See Provider Reference: Healthy Child Development Disclaimer: Given the constantly evolving nature of evidence and changing recommendations, the Rourke Baby Record is meant to be used as a guide only. |
| RDED2 | Richmond Diabetes Class | Diabetes Class Report Visit Date: «Letter.Letter.Today» Attended Diabetes Education Day «» Class Content Reviewed: the following topics were discussed: - Pre & post meal glucose and A1C target - Guidelines for glucose monitoring - Exercise for people with diabetes - Staying healthy with diabetes with a focus on foot care - Sick day management guidelines - CDA’s “Beyond the Basics Meal Planning Guide” with recommendations for 45-60g carbohydrate with meals and 0-15g with snacks - Label reading, meal planning - Target goals (CDA) - Staying healthy with diabetes - ACR, BP goals - Eye/oral health - Frequency of lab tests - Travel, immunizations, sick time - Individual lipid profiles, strategies to improve blood cholesterol levels using “Cholesterol Story” - Sodium/ DASH diet/ Mediterranean Diet - Weight goals - Tobacco cessation - Vitamins, minerals - Eating out - Stress management Planning and Recommendations: General Recommendations for All Clients Attending Diabetes Education: (per CDA 2013 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10mmol/L pc meals 3. A1C ≤ 7% - measure every 3-6 months 4. Blood pressure < 130/80 5. LDL ≤ 2.0mmol/L; Total cholesterol/HDL ratio < 4.0 mmol/L 6. 3 balanced, evenly spaced meals, low glycemic index 7. Moderate aerobic activity – minimum of 30 mins 5x/week; include resistance min 2x/week 8. Be a non-smoker Follow-Up Plan: Encouraged to continue in day «» of the Diabetes Education Program Group facilitated by: «» «» |
| RDEDFU | Richmond Diabetes Follow Up | Diabetes Follow Up Visit Date: «Letter.Letter.Today» Today your patient attended Day «4/5» of the Diabetes Education Centre living with Type II diabetes program, which is designed to assist individuals to learn Chronic Disease Management. Included review of: - Lab tests and target values - Signs and symptoms of hyperglycemia and hypoglycemia - Treatment of hypoglycemia - Blood Glucose Monitoring - Benefits of self blood glucose monitoring - Suggested test schedule - When to follow up with physician or healthcare provider - Pattern management using a journal - Benefits of activity - Nutrition - Creating a healthy eating environment - Goals and strategies for menu planning - Carbohydrate recommendations - Heart Healthy Eating - Medications used to manage diabetes - Staying healthy with diabetes – prevention of complications - Strategies for self-care - Sick day management guidelines Planning and Recommendations: General Recommendations for All Clients Attending Diabetes Education: (per CDA 2013 Clinical Practice Guidelines) 1. See physician a minimum of twice a year for a visit specific to diabetes management 2. Target glucose of 4-7 mmol/L ac meals and 5-10mmol/L pc meals 3. A1C ≤ 7% - measure every 3-6 months 4. Blood pressure < 130/80 5. LDL ≤ 2.0mmol/L; Total cholesterol/HDL ratio < 4.0 mmol/L 6. 3 balanced, evenly spaced meals, low glycemic index 7. Moderate aerobic activity – minimum of 30 mins 5x/week; include resistance min 2x/week 8. Be a non-smoker Follow-Up Plan: «» Group facilitated by: RN: «» RD: «» MD: «» |
| RDEGD | RDE GDM Class - Group Charting Template | Visit Date: «Letter.Letter.Today» Attended GDM Class Content Reviewed - the following topics were discussed: RN Instructions: GDM defined Insulin Action Insulin resistance Exercise: amount/appropriate type of safe exercise Urine ketone testing Rationale/consequences of GDM hypertension / high risk pregancy large baby / C-section dislocated baby shoulder neonatal hyperinsulinemia neonatal with respiratory distress neonatal hyperbilirubinemia possible high risk for baby to have childhood obesity, and Type 2 diabetes later in life BS Machine, demonstration Testing 5 min before meal / GDM target BS Testing 1 hour after the first bite / GDM target BS Expected rise of blood sugars Rationale / Trouble shooting blood sugars diet exercise medication Role of Insulin Clearly explain probability of the use of insulin to control BS When will insulin be considered (limitations of safe diet/exercise/#s of elevated BS) Role of Diabetes Specialist Dietitian Instructions Looking at your plate Identifying different food groups Identifying foods that have carbohydrate Relationship b/w carbs and BS Relationship b/w carbs / fiber / BS Relationship between a mixed meal and blood sugar rise Carb Counting OR Portion Control / Food Groups Timing of meal First meal should be within one hour of wakening 3 meals a day Meals should be 4-6 hours apart Snacks How big should a snack be Carb value of the snack Example of snack choices (protein/veggie/starch) Timing (am/pm/hs) Snacks must be 2 to 2-1/2 hours away from any other meal Exercise RN «» RD «» |
| RDEIS | Richmond Diabetes Education - Insulin Start | Insulin Start: Instructions included in this visit: PEN use Hypoglycemia Management How, When and Where to give insulin Insulin Storage, Expiry Action times of prescribed insulin(s) Diet (timing, amount of food) Target blood sugars, keeping records Ketones Lipotrophy Physiology of diabetes A1C Exercise (insulin resistance) Medications Complications (briefly) Diet (basic diet info, timing, amounts) Meter teaching «» |
| RDIGT | Richmond Diabetes Education - Prediabetes Class | Pre-Diabetes Check List o Taught by RN and RD in 3 hour group session Class content · Define Diagnosis · Labs interpretation · Insulin resistance · Gluconeogenesis, Liver ‘leaking’ glucose related to low carb diets and timing of meals, including importance of breakfast · Exercise, daily brisk activity for 30-60 minutes · Goal setting · Diet CDA handout “Just the Basics” · Managing Diabetes Abbot/CDA booklet · Low Glycemic Index · Progressive nature of Diagnosis · Review the possible risk factors contributing to DM · Chronic disease self-management, goals should be self-directed, realistic and achievable. Not “my doctor wants me to lose 50lbs”…what do you want and how are you going to do it. RN: RD: |
| RECTA | Recreation Therapy Initial Assessment | |
| REFNA | Referral Not Accepted | The above-named patient has not been accepted for referral, due to: The patient is already receiving palliative care consultation at the BCCA Pain and Symptom Management Clinic. Please follow up with the clinic for questions around further symptom management. or The patient is not a resident of Vancouver. |
| REJECT | Reject Referral from MS/NMO Clinic | Thank you for your consult request. It sounds as though it would be more apprpriate for a general neurologist. As a subspecialty clinic, we cannot see all referrals unless there is a strong suspicion of MS or NMO. As a result, we are able to offer rapid access to patients with MS and NMO. Sincerely, Robert Carruthers MD |
| REOPS | Redirected Episodic Overdose Prevention (calls REOPSTEXT) | |
| REOPSTEXT | Redirected Episodic Overdose Prevention (TEXT ONLY) | Situation: (describe circumstances that lead to service not being provided)«» Action: (actions were taken – i.e. redirected to another site, given narcan, had overdose prevention conversation)«» |
| RESCARE | Residential Care Admission (VCH/PHC EMR) | Admission Date: «» Admitted from: [ «» ]Home [ «» ]Hospital: «» SDM: «» Prior Advance Directive: «» Level of Intervention: [ «» ]Level 1 [ «» ]Level 2 [ «» ]Level 3 [ «» ]Level 4 Social History: [ Enter social history in Problems ] Goals of Care: “What are your hopes/goals for your stay at LMP?” «» Discussed with: «» Summary of Events leading to Residential Care Admission: «» Past Medical History: [ Enter past medical history in Problems ] Allergies: [ Enter allergies in Problems ] Medications on Admission: [ Enter medications in Usual Medications ] Ambulation: [ «» ]Independent [ «» ]Cane [ «» ]Walker [ «» ]Wheelchair Transfers: [ «» ]Independent [ «» ]Assist [ «» ]Lift [ «» ]Type: «» Falls: [ «» ]Yes: «» [ «» ]No Diet: [ «» ]Type: «» [ «» ]Consistency: «» Bladder: [ «» ]Continent [ «» ]Toilets self [ «» ]Incontinent Bowels: [ «» ]Diarrhea [ «» ]Constipation [ «» ]Continent [ «» ]Incontinent Physical Exam: Vital Signs: BP «» PR «» TEMP «» RR «» SaO2 «» General: «» Head & Neck: «» Heart Sounds: [ «» ]S1 «» [ «» ]S2 «» [ «» ]S3 «» [ «» ]S4 «» Murmur: «» JVP: «»  Recent Lab Values: «» Resp: «» Abdomen: «» Breasts: «» Peripheral: «» Skin: «» Cognition: [ «» ]Intact [ «» ]Impaired [ «» ]MMSE: «» Pain: «» Weight «» [ «» ]Wt Stable [ «» ]Unknown [ «» ]Wt Loss: «» Investigations: «» Other: «» Assessment: Dementia Stage: [ «» ]Mild [ «» ]Moderate [ «» ]Severe [ «» ]Very Severe Frailty Stage (1-9): «» Polypharmacy: [ «» ]Yes [ «» ]No Active Diagnoses: «» Plan: 1. DOI Level: «» Discussed with: «» 2. Meds D/C or Planned D/C: «» 3. Request records from: «» 4. «» 5. «» 6. «» 7. «» |
| RESP | Screened for communicable respiratory infections | screened for communicable respiratory infections and self-isolation directives and negative |
| REVIEW | Reviewed by Stamp | Reviewed by - «Letter.LoggedOnUser.FullName» on «Letter.Letter.Today» at «Letter.Letter.CurrentTime» |
| RKMD | Rapid Kadian Titration (calls RKMDTEXT) | |
| RKMDTEXT | Rapid Kadian Titration (TEXT ONLY) | Precautions: Reviewed the following comorbidities contraindicating or necessitating increased precautions be taken during titration: -Patient age >60: «» -Concurrent CNS depressant use, including alcohol/benzodiazepine/GHB use: «» -Severe respiratory disease: «» -Cirrhosis: «» -Moderate-severe chronic kidney disease (eGFR< 30): «» Initial Assessment History Current substance use: See nursing note for details Previous max OAT dose: «» Physical Exam «» Investigations -Most recent UDS:«Letter.Patient.Macro.LASTUDS» -Most recent Cr: «Letter.Patient.Macro.LATESTCREATINNE» -Most recent liver function tests: Last AST «Letter.Patient.Macro.LATESTAST» Last ALT «Letter.Patient.Macro.LATESTALT» Last Total Bilirubin «Letter.Patient.Macro.LATESTTOTALBILI» Last Albumin «Letter.Patient.Macro.LATESTALBUMIN» Last INR «Letter.Patient.Macro.LATESTINR» Last Platelets «Letter.Patient.Macro.LATESTPLATELETS» Last Gamma GT «Letter.Patient.Macro.LATESTGGT» -Abdo US, if any: «» Plan: 1. NRT Offered 2. Patient transferred to TIZ for observation 3. Safe to proceed with rapid kadian titration 4. Titration explained to patient, questions answered, informed consent obtained. Consent form signed 5. «For starts/restarts: If POSS less than or equal to 2, administer morphine oral liquid 100-200mg q1h prn (100mg first dose, followed by 200mg x 2 doses, all doses separated by 1 hour) to a maximum of 500mg.» «For re-titrations after missed doses: If POSS less than or equal to 2, administer morphine oral liquid 200mg q1h prn to a maximum of 800mg.» 6. Evening M-eslon dose (100% of short acting morphine dose): «» 7. Post-titration kadian dose: (sum of titration day's morphine dose): «» 8. Include on post-titration kadian rx: "Dose titrated in RAAC. OK to administer 1000 (one thousand) mg 9. Letter sent to pharmacy explaining Rapid Titration Protocol. 10. Task sent to OOT Nurse Prescribers (New Task>Group>OOT Nurse Prescribing (OOT-RNRX)) indicating follow up post-rapid kadian titration, patient’s hangouts/phone number/physical description. See nursing note for details of morphine doses and post dose assessments. |
| RM | Risk Mitigation Prescribing Enrollment Form | |
| RPN | Review Panel Note (macro only) | |
| RRTAOR | Recovery Response Team – Attempted Outreach/Contact | |
| RRTAPPT | Recovery Response Team – Appointment Accompaniment | |
| RRTCC | Recovery Response Team – Care Coordination | |
| RRTCI | Recovery Response Team – Crisis Intervention | |
| RRTDC | Recovery Response Team - Discharge (calls RRTDCTEXT) | |
| RRTDCTEXT | Recovery Response Team - Discharge (TEXT ONLY) | Reason for discharge: «» Summary of care: (with brief overview completed goals) «» OAT, primary care, other health care providers involved: «» Housing/income/food security: «» Additional supports\resources: «» |
| RRTI | Recovery Response Team – Intake Note (calls RRTITEXT) | |
| RRTITEXT | Recovery Response Team – Intake Note (TEXT ONLY) | Referral Source: «» Summary: (current location, care plan, age, health conditions, social determinants of health, legal engagement, gender identity, goals of care, ct’s goals, hx of hosp visits/acute settings & wdm/tx, housing, income, food security.) «» Goals to attempt to complete: (from referral, check box portion) «» Substance use: (type & risk, route and severity; not on OAT, hx of seizures,) «» Indigenous identity: (status number, current cultural supports or if needed, Nation, etc) «» Primary Care/OAT provider/other health care providers/attached services/MHT: «» Recovery goals: (health or social) «» Plan: (immediate or ongoing from prior health care providers, include which case manager ct is being assigned to along with any upcoming time sensitive dates) «» |
| RRTOR | Recovery Response Team – Outreach/Client Contact | |
| RRTR | Recovery Response Team - Referral Received | |
| RRTRD | Recovery Response Team - Referral Declined | |
| RRTRPI | Recovery Response Team – Review Prior to Intake | |
| RSGALLERGY | Allergy shot NOTE | Allergy shot NOTE (RSGallergy\) Ongoing conditions - «none» Medications - «none» Allergen type - «type here» Treatment indication (rhinitis, conjunctivitis, etc) - «type here» Dose number - «x» Dose amount - «x»mL Previous local reactions? - «no» Previous systemic reactions? - «no» Premedication? - «no» Severe asthma? - «no» On beta-blockers? - «no» Pregnancy? - «no» On exam - «looks well, PEF not done» Issues and Plan Allergy shot - «x»mL injected SC into «L» posteriolateral arm. Anaphylaxis risk – Patient instructed to wait in waiting room for 30min after injection. To notify staff if signs of reaction develop (resp, GI, CVS, skin). Consider epinephrine pen prescription. 0.3-0.5mg epinephrine IM if mild or moderate symptoms develop. Go to nearest emergency department if signs of anaphylaxis occur in the hours following injection. Patient information and web resources - www.uptodate.com/contents/allergy-shots-the-basics Follow-up - «2» weeks. Avoid exercise 1-2h before visit, and consider oral antihistamine premedication. |
| RSGHIVPC | This patient receives HIV primary care at Raven Song | This patient receives HIV primary care at Raven Song (rsghivpc\) |
| RSORT | RSG ORT Clinic RN note | RSG ORT Clinic RN note (rsort\) Reason for visit today - «short description here» Current opiate replacement (include dose) - «suboxone/methadone/other/none» Has THN training? - «yes/no» Has THN kit? - «yes/no» Hep A and B immune? - «yes/no - document on problem list if immune» Medinet reviewed - «yes/no» Has the patient missed any doses in the past five days? - «yes/no and which days» Engaged in counselling? - «yes/no - document details on problem list» Last urine drug screen: luds«type '\' here» |
| RSORT1 | ORT Clinic RN note - Intake | ORT Clinic RN note - Intake Visit (rsort1\) Past medical hx - «brief PMH review, mental health, ED visits, overdoses, hospitalizations, major surgeries, etc» Medinet review - «list current meds, relevant previous meds» Adverse drug reactions - «ask patient and note those listed on Medinet» Social history - «comment on housing, finances and MSP, relationships, children, driving, etc» Current substance use tobacco smoking - «» cannabis - «» ups (crystal, crack, cocaine, etc) - «» downs (heroin, opiates, benzos) - «» party drugs (ecstasy, ketamine, GHB, etc) - «» etOH - «» Addictions hx - «consultations, treatments, detox, recovery, 12-step, counselling, behavioural addictions, etc» Immunizations - «consider HAV, HBV, Td, HPV, pneumovax, etc» Objective BP «» Weight «» Height «» «note signs of intoxication or withdrawal, track marks, consider COWS» Last urine drug screen: luds«type '\' here» First visit checklist Links to counselling? - «yes/no and give details» THN kit and training - «yes/no and document in problem list» Bloodwork - «consider CBC, lytes, AST, ALT, bili, INR, Albumin, creatinine, urea, HIV, syphilis, Hep A IgG, Hep B sAg, cAb, sAb» Urine tests - «consider rapid UDS, pregnancy test, GC/Chlam» |
| RSORT2 | ORT Clinic RN note | ORT Clinic RN note (rsort2\) Reason for visit today - «short description here» Current opiate replacement (include dose) - «suboxone/methadone/other/none» Current substance use - «ask about opiates, etOH, benzos, other sedatives» Has THN training? - «yes/no - document on problem list if done» Has THN kit? - «yes/no» Hep A and B immune? - «yes/no - document on problem list if immune» Medinet reviewed - «yes/no - ensure that doses are "filled", not "reversed"» Has the patient missed any doses in the past five days? - «yes/no and which days» Engaged in counselling? - «yes/no - document details on problem list» Objective - «consider vitals check, comment on signs of intoxication or withdrawal» Last urine drug screen: luds«type '\' here» |
| RSR | MHSU Rehab Services Referral | MHSU Rehab Services Referral Service requested: (delete those not applicable, ensure a separate referral to each discipline is created, ensure client consents to referral(s)) Recreation Therapy Occupational Therapy IPS Vocational Counselling Reason for Referral: (primary reasons for the referral, client goals, peer support services) Diagnoses: What are client's key strengths? (e.g., strong support system, financial resources, strong motivation, positive outlook) What significant challenges is the client experiencing? (e.g., active psychosis, significant depressed mood, high anxiety, limited support system, lack of motivation, limited finances) Priority Level: Urgent (1-2 weeks) Moderate (1-3 months) No pressing timeline If “Urgent” provide rationale and speak with the rehab team (e.g., imminent housing instability, social income assistance withdrawn, client readiness for recovery) Tips on how to best engage with client: (e.g., time of day to contact client, prefers email contact or text message, reminder calls, initial joint visit with case management) Additional information: (e.g., safety concerns re: substance use, need for interpreter, seizure disorder) Additional Information for IPS Vocational referrals only (delete if not applicable): What is client saying about work? Why do they want to work now? What type of job do they prefer? Any additional information you might have related to client's vocational goals (e.g., type of job, hours, etc.): How might the client’s mental health impact their ability to work? |
| RTAZ | Referral Triage - Alzheimer's Clinic | |
| RTD | Repeat test date | Repeat test date: «» ...................................................... |
| RTMS | Referral Triage - MS Clinic | |
| RVC | Radiology Template - Voiding Cystourethrogram | NOTE TO CLINIC: Fax Requisition RELEVANT HISTORY/REASON FOR EXAM: «» BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| RX | Rx Refill Request Due | Rx Refill Request Due: |
| S | Signature of logged on user | - «Letter.LoggedOnUser.Title»«Letter.LoggedOnUser.FullName» on «Letter.Letter.Today» at «Letter.Letter.CurrentTime» |
| S10 | Primary Syphilis | Primary Syphilis |
| S20 | Secondary Syphilis | Secondary Syphilis |
| SA | Sexual Assault - Post Exposure Incident | Post exposure incident Subjective Reports sexual assault/potential sexual exposure: «date/time:» «memory lapse date/time» Nature of assault: «oral» «vaginal» «anal» «digital penetration» «unknown» «physical injury:» «Any known risk history re: assailant(s):» Assessed re: symptoms, immunization history, previous STI/HIV testing and pregnancy/contraception: see CPS STI form Mental health: «» Social supports: «» Objective Physical exam: «no apparent abnormalities» «variances noted:» «declined physical exam» «deferred exam and care to Sexual Assault Services (SAS) as per client consent» «Urine pregnancy test if indicated:» «HIV POC INSTI: if indicated» Assessment «Sexual assault within 7 days: offered referral to SAS; accepted or declined» «Sexual assault 7-21 days ago» Plan Informed consent: offered recommended care as per DST STI/HIV testing: «done on site; client aware tests are not for forensic purposes» «declined testing» «referred to SAS for care, +/- forensic collection; offer WAVAW for accompaniment to hospital» Prophylactic treatment: «provided as per DST» «declined, advised to repeat GC, CT testing in 7-14 days» Emergency contraception: «provided as per DST» «declined» «N/A» PEP: «recommended due to significant HIV risk and assault less than 72hrs as per BCCfE PEP guidelines» «declined» «N/A» «Vaccines:» Referrals to support: «WAVAW» «Crisis Line» «VictimLINK» «Sexual Assault Support Centre (SASC); for UBC students» «BC Male Survivors BCSMSSA» «other» Follow up: advised to repeat testing as per DST |
| SAAP | drop-in Subjective | Subjective «» Objective «» Issues and Plan «» Time - «» |
| SAM | Sam Tool | |
| SBAR | SBAR Template | Situation: «» Background: «» Assessment: «» Recommendation: «» |
| SBE | Template - SBE Endocarditis Propylaxis Guideline (AccelEMR) | Subacute Bacterial Endocarditis Prophylaxis - Guidelines: (J Am Coll Cardiol, 2008; 52:676-685, doi:10.1016/j.jacc.2008.05.008) http://enotes.tripod.com/sbe.htm A. Warranting Conditions: Previous Endocarditis Prosthetic valve Congential heart disease (CHD): unrepaired cyanotic CHD completely repaired CHD using prosthetic material (only for first 6 months) (*NOT for native valve disease of any kind -not AS, MS, MR, MVP with or without prolapsed) B. Warranting Procedures: Only for oral procedures where the gingiva/mucosa is manipulated. (*NOT for GI or GU procedures) C. Antibiotic Regimens: Prophylactic Regimens for Dental, Oral, Respiratory Tract Procedures  1Total children's dose should not exceed adult dose 2Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins |
| SCR | ICMT Screen | Referring Collateral: «» Housing: «» Income: «» Medical History: «» Doctor: «» Diagnosis: «» Mental Health History: «» Psychiatrist: «» Diagnosis: «» Substance Use: «» Criminal Justice Involvement: «» Family Supports: «» Client Strengths and Goals: «» Summary: «» |
| SEL | Early Latent Syphilis | Early Latent Syphilis |
| SELP | Early Latent - Probable Syphilis | Early Latent - Probable Syphilis |
| SERO | Serofast | Serofast |
| SEXI | Template - Shoulder Exam - Impingement (AccelEMR) | Examination of the «R/L» shoulder (For details go to Prov Ref - Look for shoulder): Inspection: Symmetrical without visible deformity, muscle wasting, swelling, erythema, or ecchymosis Range of Motion: Abduction: «»0 Int. Rotation: thumb reaches «» cm from tip of scapula AC joint: «non tender» to palpation Scarf test (pt grabs opposite shoulder-examiner pushes further laterally) - «Neg» Impingement Tests: Painful arc - «Positive» Neer (arm by ear-forced posteriorly) - «Positive» Hawkins ("crank arm") - «Positive» Yokum (pt grabs opposite shoulder & resists downward pressure) - «Positive» Rotator Cuff Integrity: Supraspinatus - Jobe test ("Empty Can") - «N» Infraspinatus - Resisted ext. rotation @ 450 - «N» Subscapularis - Lift off test (hand behind back - resisted liftoff) «N» Long head of biceps: Palpation - «Non tender» Speed test (palm up, elbow 900,resisting downward pressure) - «Neg» |
| SEXN | Template - Shoulder Exam - Normal (AccelEMR) | Examination of the «R/L» shoulder (For details go to Prov Ref - Look for shoulder): Inspection: Symmetrical without visible deformity, muscle wasting, swelling, erythema, or ecchymosis Range of Motion: full in all directions without pain AC joint: «non tender» to palpation Scarf test (pt grabs opposite shoulder-examiner pushes further laterally) - «Neg» Impingement Tests: Painful arc - «Neg» Neer (arm by ear-forced posteriorly) - «Neg» Hawkins ("crank arm") - «Neg» Yokum (pt grabs opposite shoulder & resists downward pressure) - «Neg» Rotator Cuff Integrity: Supraspinatus - Jobe test ("Empty Can") - «N» Infraspinatus - Resisted ext. rotation with elbow @ 900 - «N» Subscapularis - Lift off test (hand behind back - resisted liftoff) «N» Long head of biceps: Palpation - «Non tender» Speed test (palm up, elbow 900,resisting downward pressure) - «Neg» |
| SHAVE | Template - Shave Excision (AccelEMR) | Informed consent obtained. Area infiltrated with xylocaine 1% with epi. Skin prepped and draped in sterile fashion. Scalpel used to perform shave « biopsy vs excision removing entire lesion» which was sent to pathology. Capillary bleeding controlled with application of Drysol. Wound care instructions given. (If complete excision 13620 or 6069 if face vs. 13600 if bx) |
| SHB | Syphilis High Blood | Syphilis high blood; Copy given to clinic physician |
| SHIFTR | SHIFT/Home Stabilization Program (YHSP) Rounds | |
| SHORELINEIA | Initial Patient Assessment for Shoreline Space(calls Text) | |
| SHORELINEIATEXT | Initial Patient Assessment for Shoreline Space (Text Only) | Date of Assessment: «» Assessment Completed: in-person patient assessment/telephone conversation with patient/telephone conversation with family/telephone conversation with SPH clinician (MRP/CNL/CML/Nurse/SW/MRL) «» Acute-to-Acute Criteria Reviewed (Y/N): «» Patient appropriate for Shoreline Space Transfer (Y/N): «» If no, what exclusion criteria does the patient meet?: «» Is the SPH Care Team considering step-down treatment to trial if patient can tolerate for a Shoreline Space transfer? (Y/N): «» |
| SHORELINEPDC | Pre-Discharge Checklist for Transfer to Shoreline Space | |
| SHORELINEPDCTEX | Pre-Discharge Checklist for Transfer to Shoreline Space(TEXT) | Date: «» Shoreline Space exclusion criteria reviewed (Yes/No): «» Patient appropriate for Shoreline Space transfer (Yes/No): «» If no, what exclusion criteria does the patient meet?: «» List of Medication (including PRNs): «» O/SC/SL Route Confirmed for Transfer Medication (Yes/No /NA): «» Plan for Step-Down Treatments (Yes/No): «» SPH aware step-down treatments required to be in place 2 hours in advance (Yes/No/NA): «» Patient Mobility: Independent/1PA/2PA/Lift Required «» Patients preferred method for transfer: Wheelchair/bed/walker «» Interpreter Required (Yes/No): «» Funeral Arrangements Confirmed (Yes/No): «» Review Risk Screen (Yes/No): «» Code Status: «» Confirmation of MOST Form and No CPR Form (Yes/No):«» Additional Relevant Tubes/Drains/Appliances: If none, write N/A, only include the applicable item below VAC (Yes/No): «» Catheter (Yes/No): «» Ostomy (Yes/No):«» Trach (Yes/No): «» Oxygen (Yes/No): «» Chest Tube (Yes/No): «» Suction (portable only) (Yes/No): «» Nephrostomy Tube (Yes/No): «» G tube (Yes/No): «» NG Tube (Yes/No): «» Others: «» Relevant Family Dynamics: «» Confirmation patient continues to be appropriate for Shoreline Space transfer (Yes/No):«» |
| SIGN | Signature of logged on user | - «Letter.LoggedOnUser.Title»«Letter.LoggedOnUser.FullName» on «Letter.Letter.Today» at «Letter.Letter.CurrentTime» |
| SINJ | Template - Shoulder Injection (AccelEMR) | After obtaining consent (including discussion of risks including allergy, skin atrophy, and septic arthritis), the «R or L» shoulder was injected with 40 mg of kenalog and 1 cc of xylocaine without epi in the subacromial space using a 25 g syringe. Well tolerated. Billing Code: 15 |
| SLL | Late Latent Syphilis | Late Latent Syphilis |
| SLLDX | Late Latent Syphilis Diagnosis | Date tested: «» TP EIA: Reactive RPR: «» TPPA: «» Date tested 2: «» TP EIA: Reactive RPR: «» TPPA: «» Diagnosis: Late Latent Syphilis Treatment recommendation: Bicillin 2.4 MU IM weekly x 3 weeks Partner follow up: Long term partners should be tested, and if your patient has given birth to any children, the children should be tested as well. «Pregnancy test recommended (patient able to get pregnant and ≤ 50 years» |
| SM | Smokes | Smokes |
| SN | Specialist Note | |
| SNPI | SNP Intake Assessment | CC: «» HPI: «» GOALS OF CARE: · Understanding of current illness: «» · Goals/hopes/values: «» · Fears/worries: «» · Additional info to support pt centered care: «» PAST MEDICAL HISTORY: · Sx «» · Hosp «» · Immunizations: «» MEDICATIONS: · Pharmanet: «» · OTCs: «» · Herbal supplements: «» ALLERGIES: «» FAMILY HISTORY: · Blood pressure «» · Arthritis «» · Lung disease «» · Diabetes «» · Cancer «» · Heart disease «» · ETOH «» · Stroke «» · Mental health «» SOCIAL HISTORY: · ETOH/Drugs: «» · Smoking: «» · Sexual hx: «» · Family/social support: «» · Living situation: «» · MRP: «» · Specialists: «» · Pharmacy: «» ROS/ General: «» HEENT: «» Breast: «» Cardiovascular: «» Respiratory: «» Gastrointestinal: «» Genitourinary: «» Integument: «» Neurological: «» Musculoskeletal: «» Endocrine: «» Psychiatric: «» Blood-Lymph: «» Allergic-Immunologic: «» O/ VITAL SIGNS: Weight «» kg, blood pressure «», pulse «», temp «», RR «», SpO2 «». Clinical Frailty Scale: «» Risk for Readmission Assessment Score: «» General: «Orientated X 3, no acute distress, appropriate responses» Skin: «pink, warm, no rashes, no suspicious nevi» HEENT: «TM visualized with cone of light, PERLA, EOMs intact, no nasal polyps, septum intact, no lymphadenopathy, no thyromegaly, no carotid bruits» CV: «S1S2 clear, no murmurs or extra heart sounds, No JVD» Resp: «clear AE to bases, no adventitious sounds» Abd: «soft, non-tender, BSX4, no masses, no hepatosplenomegaly, no inguinal adenopathy, no femoral/abdominal bruits» MSK: «full ROM in all joints of upper/lower extremities, good muscle bulk and tone, strength 5/5 throughout» PVS: «extremities pink, warm, no edema, no varicosities or stasis changes, calves supple and non-tender, brachial/radial/femoral/popliteal/dorsalis pedis/posterior tibialis pulses +2 and symmetric» Neuro: «CN II-XII grossly intact» ASSESSMENT/ Diagnosis and differential diagnosis: «» PLAN/ Laboratory: «» X-Rays: «» Medications: «» Patient Education: «» «Red flag symptoms discussed, and patient encouraged to present to ER if emergent health concerns.» Follow-up: «» HCS/ «Referrals/notes to HCS staff.» |
| SOAPNOTE | Template (SOAP) - Basic Visit (AccelEMR) | Subjective: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «» Objective: «» Assessment / Plan: Follow up «Letter.Patient.Next Appointment.Date»«» «» |
| SOAPTEST | SOAP | S: «» O: «» A: «» P: «» Y: |
| SOG | Standing Order Gilwest | Standing Order: every 1 - 3 months from «» to «» **DO NOT draw HIV VL on Friday or Saturday** |
| SP | Suicide Prevention Safety Plan (calls SPTEXT) | |
| SPS | Synopsis Tab - Smoking (AccelEMR) | Smokes «Y/N» Stage of Change: Precontemplating «» Contemplation (Getting Ready) «» Preparation (Ready) «» Action «» Maintenance «» Relapse «» Interested In quitting in next 6 months «Y/N» Age when started: «» Amount Smoked (mm/yy-cigs/day): «» Reasons to smoke: «» Barriers to quitting: «» Quitting Attempts: DateDurationMethodComplications/Lessons Learned «Letter.Patient.DateLastSeen»«»«»«» «»«»«»«» «»«»«»«» «»«»«»«» «»«»«»«» Notes: «» |
| SPTEXT | Suicide Prevention Safety Plan (TEXT ONLY) | 1.Warning Signs that a crisis may be developing «» 2.Coping strategies I can do to take my mind off my problems«» 3.People and social settings that provide distraction and/or support «» 4.People I can ask for help «» 5.Make my Space Safer or go to a safer space «» 6.Contact Crisis Lines or Other Services: BC Crisis Centre 1-800-SUICIDE (24h), Mental Health Support Line 310-6789 (24h), Kuu-Us Indigenous Crisis Line 1-800-588-8717 (24h) 7.Receive Emergency Services: Call 911 or go to the Emergency Department at the nearest hospital |
| SPV | School Physician Visit | School Physician Visit School: <<>> |
| SRAC | TCB-SRA - Appointment Confirmation | Patient confirmed for «first/second» surgical readiness assessment on «date» at «time» with «assessor» for a «virtual care/in person/telehealth» appointment. |
| SRAW | TCB-SRA - Patient Added to Waitlist | Patient added to Trans Care BC's waitlist for surgical readiness assessment. |
| SSAMA | Safe Supply Nursing Assessment and Medication Administration | Safe Supply Nursing Assessment and Medication Administration Pre-dose assessment: Most recent substance use and amount (including alcohol): «» General appearance: «» POSS score: «POSS score, if score 3 or 4, assess vitals» Smell of alcohol, symptoms of intoxication or distress «yes/no, if present describe and assess vital signs» Pre-dose vital signs, if applicable (SpO2, RR, PR, BP and temp): «» Medication administration: Medication, dose, route: «» Peripheral IV site assessment (if applicable): «» Injection support: «yes/no; describe briefly if yes» Dose tolerated well: «Y/N» Dose witnessed by staff: «Y/N» Post-dose assessment: POSS score: «POSS score, if score 3 or 4, assess vitals» Symptoms of drug poisoning or distress «yes/no, if present describe and assess vitals» Post-dose vital signs, if applicable (SpO2, RR, PR, BP and temp): «» Plan: Any follow-up required: «» Participant can return for next dose at: «time» |
| SSC | Safe Supply Collateral Info (calls SSCTEXT) | |
| SSCTEXT | Safe Supply Collateral Info (TEXT ONLY) | Any history or current OAT? (Specify if Kadian, Methadone, Suboxone - start date or length of time if details available) «» Any recent UDS Results? (type luds\) «» Any previous Addiction Team Consult Notes? Comments «» Current Substance Use Benzodiazepine: «» Opioids: «» Stimulants: «» Alcohol: «» Nicotine: «» Comments: «» Significant findings related to previous drug use «» Where will they be self-isolating? Opus «» Congregate Setting «» SRO «» Clinical Assessment done? Last clinical assessment in client record by MRP «» Last OR Nursing Outreach Assessment «» Client Preferences for Safe Supply Medications (Discuss directly with client) «» Additional Notes «» |
| START | Substance Treatment and Response Team | |
| STARTD | START- Discharge Note | |
| STARTE1 | START ETOH Day 1 | |
| STARTE2 | START ETOH Day 2 | |
| STARTE3 | START ETOH Day 3 | |
| STARTE4 | START ETOH Day 4 | |
| STARTE5 | START ETOH Day 5 | |
| STARTE6 | START ETOH Day 6 | |
| STARTE7 | START ETOH Day 7 | |
| STARTEAC | START ETOH After Care | |
| STARTF | START Follow-Up | |
| STARTI | START Intake Assessment | |
| STI | Screening for STI | |
| STIEXAM | STI Physical Exam Variance | STI Clinical Exam Subjective: Presenting symptom(s): «» «see CPS STI Form» Sexual health history: «see CPS STI Form» Objective: Physical exam done; variances noted: Mouth/throat: «lesion» «redness» «swelling» Trunk/forearms/palms: «rash» «lesion» Inguinal nodes: «swelling» «tenderness» Penis: «rash» «lesion» «irritation» Urinary meatus: «discharge» «redness» «swelling» «lesion» Scrotum: «rash» «lesion» «irritation» Testicular exam: «tenderness» «lump» Perianal area: «lesion» «bleeding» «discharge» «irritation» Vulva: «redness» «swelling» «lesion» Vagina: «abnormal discharge: color/amount» «amine odor» «pH:» «lesion» Cervix: «cervical exudate» «lesion» «friable» «edema» «IUD strings» Bimanual exam: «fundal tenderness» «cervical motion tenderness (CMT)» «adnexal tenderness» Assessment: Clinical/presumptive diagnosis: «» Plan: STI testing done: see lab requisition(s) «swabs exposed sites» «serology» Consult/referral: «» «N/A» Treatment: «» Client education: «see CPS STI Form» Follow-up: «» |
| STIFU | STI follow-up | STI Follow-up: sign lab result in EMR Informed client re: positive result «CT»«GC»«Syphilis»«LGV» Client education as per STI DST Treatment Plan: «Already treated as contact»«BCCDC 655/Bute Clinic: appointment booked»«Other» Partner notification: «client will inform partner(s)»«requests PHN assistance» HIV PrEP: «N/A»«on PrEP»«Discussed; plan:»«Declined; reasons:» |
| STII | STI Assessment | History: Reason for visit: «» Last STI screening: «» Any known previous positive results?: «» Any current symptoms: «» Date of last sexual contact: «» Gender(s) of partners: «» Types of sex/sites for testing: «» Any contraception/barrier method use?: «» If applicable: Last menstrual period (if applicable): «» Any pregnancy risk (if applicable)?: «» Last PAP/cervical cancer screening (if applicable): «» Physical Findings/Screening: Physical exam findings: «» CT/GC/Trich testing collected: «» BV/Yeast smear collected (if applicable): «yes/no» Serology collected (please specify): «» Other testing: «» Treatment/Education: If providing treatment/medications: Any Known Drug Allergies?: «» Any regular medications: «» Any treatment/intervention provided?: «» Any safer sex/harm reduction teaching provided?: «» Discussed window periods?: «» Follow Up Plan: Plan for results follow up: «leave message at Insite,» «call/text client at phone #:,» «call client’s building,» «other» |
| STIPOS | Positive STI result | Positive STI result Follow-up initiated to inform client, «arrange treatment» «already treated as contact», discuss partners |
| STIT | STI Treatment (calls STITTEXT) | |
| STITTEXT | STI Treatment (TEXT ONLY) | Diagnosis: Syphilis «» LGV «» HSV«» CT Throat «» CT Urine «» CT Rectal «» CT Cervix/Vaginal «» GC Throat «» GC Urine «» GC Rectal «» GC Cervix/Vaginal «» Other «» Patient Education: Client Informed of Diagnosis Y«» N«» Partners Discussed «» TOC Discussed if Applicable «» Period of Abstinence Discussed «» Medication Counselling «» H208 Completed «» Results Signed «» PrEP Recommended: Yes «» No «» N/A «» If No: Client HIV Positive «» Client already on PrEP «» Female Partners Only «» Client requesting PrEP Consult «» Client referred to other provider for PrEP «» Client considered low risk (or HIRI <10) «» Client Accepted Referral: Yes «» No «» If No: Does not feel at risk «» Concerned regarding side effects «» Client already referred elsewhere «» Cost «» Will think about it «» Client not interested in PrEP «» |
| STOPDC | STOP Discharge (calls STOPDCTEXT) | |
| STOPDCTEXT | STOP Discharge (TEXT ONLY) | Summary of Care: Reason for Referral «» Treatment progress «» Critical Issues «» Reason for Discharge «» HIV Care Details: ARV Treatment Provided/Adherence «» Self Management Skills * «» HIV Primary Care Provider «» CD4 and pVL @ Discharge «» Housing & Finances: «» Addiction & Mental Health: «» Health Issues & Primary Care Details: «» Nutrition & Food Security: «» Other Issues: «» Other Professionals Involved: «» Future Recommendations: «» * Self management skills – refers to: independence with medication adherence, symptom monitoring, transmission prevention, patient understanding disease and treatment, effective communication with health care providers, stress management, physical activity, balanced diet, weight management |
| STOPIN | STOP Intake (calls STOPINTEXT) | |
| STOPINTEXT | STOP Intake (TEXT ONLY) | Background: Who referred client and when «» Client aware of referral? «» Description of client «» Presenting Concerns: Reason for Referral «» Referral Details/ STOP services required «» HIV Care Details: ARV Treatment Hx «» Self Management Skills* «» HIV Primary Care Provider «» CD4 and pVL «» Housing & Finances: «» Addiction & Mental Health: «» Health Issues & Primary Care Details: «» Nutrition & Food Security: «» Other Issues: «» Other Professionals Involved: «» Immediate Concerns and Actions Taken: «» * Self management skills – refers to: independence with medication adherence, symptom monitoring, transmission prevention, patient understanding disease and treatment, effective communication with health care providers, stress management, physical activity, balanced diet, weight management |
| STOPSD | STOP Step Down | Summary of Care: Reason for Referral Treatment progress «» Critical Issues «» HIV Care Details: ARV Treatment Provided/Adherence «» Self Management Skills * «» HIV Primary Care Provider «» CD4 and pVL currently «» Housing & Finances: «» Addiction & Mental Health: «» Health Issues & Primary Care Details: «» Nutrition & Food Security: «» Other Issues: «» Other Professionals Involved: «» Care Plan Goals/Recommendations: «» Next client F/U due date: «» Next HIV Assessment due: «» * Self management skills – refers to: independence with medication adherence, symptom monitoring, transmission prevention, patient understanding disease and treatment, effective communication with health care providers, stress management, physical activity, balanced diet, weight management |
| SU | Substance Use Services Note | |
| SUBMIC | Micro-inductn (7d): SL DWI | Micro-induction (7d): SL DWI for AM dose, PM dose carries: Day1 0.5mg (Approx 1/4 tab) ONCE. Day2 0.5mg BID. Day3 1mg BID. Day4 2mg BID. Day5 3mg. BID Day6 4mg BID. Day7 12mg ONCE. Total prescription 33.5mg (Thirty three and half mg) |
| SUBOX | Suboxone Induction | TimeCOWS scoreAmount suboxone administeredPrescriber «»«»«»«» «»«»«»«» «»«»«»«» |
| SUBOXONE | Micro-induction (7d): SL DWI | Micro-induction (7d): SL DWI for AM dose, carries rest of the day: Day1 0.5mg (Approx 1/4 tab) BID. Day2 0.5mg TID. Day3 1mg BID. Day4 2mg BID. Day5 3mg BID. Day6 4mg BID. Day7 6mg BID. Total prescription 34.5mg (Thirty four and half mg) |
| SUBS | VCH: Synopsis Tab - Substance Use History (AccelEMR) | Substance Use History Substance Route Amount Freq Age Onset Years Last use Details Alcohol « » « » « » « » « » « » Heroin « » « » « » « » « » « » «opiate» « » « » « » « » « » « » Cocaine « » « » « » « » « » « » Crystal Meth « » « » « » « » « » « » Amphetamines « » « » « » « » « » « » THC « » « » « » « » « » « » Benzodiazepines « » « » « » « » « » « » Nicotine « » « » « » « » « » « » «Other» « » « » « » « » « » « » «Other» « » « » « » « » « » « » Other Addictions: «» « » « » « » « » « » « » Screening/Assessment Tool Scores: Test Name Score Comments «» «» «» Other Details of Substance Use (Include pattern of use, reasons for use, changes over time, etc): « » Details of Withdrawals (Dates, outcomes, include history of seizures): « » Treatment HISTORY: «Facility (name) / Outpatient» «Date Started» «Duration» «Comment» «Facility (name) / Outpatient» «Date Started» «Duration» «Comment» «Facility (name) / Outpatient» «Date Started» «Duration» «Comment» «Facility (name) / Outpatient» «Date Started» «Duration» «Comment» «Facility (name) / Outpatient» «Date Started» «Duration» «Comment» Experience(s) of Abstinence/Relapse: «Date» «Duration» «Details» «Reason for Relapse» «Date» «Duration» «Details» «Reason for Relapse» «Date» «Duration» «Details» «Reason for Relapse» «Date» «Duration» «Details» «Reason for Relapse» «Date» «Duration» «Details» «Reason for Relapse» Previous Methadone Maintenance Therapy: «Date(dd/mm/yy)» «Duration» «Dose» «Details (maintenance or reduction; carry privileges; physicians; outcome)» «Date(dd/mm/yy)» «Duration» «Dose» «Details (maintenance or reduction; carry privileges; physicians; outcome)» «Date(dd/mm/yy)» «Duration» «Dose» «Details (maintenance or reduction; carry privileges; physicians; outcome)» «Date(dd/mm/yy)» «Duration» «Dose» «Details (maintenance or reduction; carry privileges; physicians; outcome)» «Date(dd/mm/yy)» «Duration» «Dose» «Details (maintenance or reduction; carry privileges; physicians; outcome)» |
| SUN | Substance Use Services - Nursing Note | |
| SUNSET | Sunset - repeat serology not available | No repeat serology available in Sunset. |
| SUPER | Superviros Positives | Result requiring follow-up. Tasked to CPS Supervisor |
| SURGBVAG | Vaginoplasty Second | Vaginoplasty Second Assessment - here today alone for 2nd ax name: pronouns: Transition History HRT – started Jan 2018 by Dr. Mattheis Surgery – no previous gender affirming surgeries ID change – legally changed her ID as of Sept 2019 Other – Has identified as female since she was a young child but only came to have language for this more recently as an adult. Eva has been dressing/presenting in feminine clothing since January 2017, has had laser hair removal to her face in January 2018. She describes this as "presenting as female 24/7 for the last year". She started socially transitioning by coming out to family and friends in the summer of 2015. She feels well supported by family and friends, as well as by online trans community. Goals: Would like to have clothes fit her better and allow for her to wear tighter clothing. Would also like to have receptive vaginal intercourse. Social Hx: Work – Housing – Support - Mental Health: Substances: PMHx - PSxHx - Meds - Allergies - Informed Consent: We reviewed the penile inversion vaginoplasty technique, as well as the Rainbow Health Ontario Surgical Summary sheet and the information video found on Dr. Crane's website at: cranects.com/vaginoplasty Reviewed procedure, potential benefits and risks, possible complications and need for revisions. We discussed the permanent impact on fertility and all serious and potentially lethal complications. We discussed as well the risks of general anesthetic. Reviewed the importance of vaginal dilations in maintaining outcome Discussed urological complications and consequent unpredictability of timeline Discussed what to expect after surgery and need for support with ADLs/IADLs. We discussed specifically the need for intensive schedule of dilations, sitz baths, and douching in the first several weeks - months post-operatively. Eva is aware that this may necessitate taking up to 3 months off from work if she is working at that time. She appears to be very well informed and to have realistic expectations She is appropriately cautious about risks and shows good judgment. She wishes to explore risk mitigation further with her surgeons. O: Well, NAD. Good eye contact. Soft spoken. Wearing a long dress and cardigan. Height: 179 cm Weight: 53 kg Body Mass Index: 16.5 kg/m^2 A/P: "Client" is a "age and gender" who meets WPATH criteria for vaginoplasty, including: persistent gender dysphoria, stable physical health, well controlled mental health, is of the age of majority and demonstrates the ability to consent. We have discussed the surgical procedure, its risks and complications, the expected course of recovery and role of follow up and dilations post-operatively. I therefore fully agree with Dr. Mattheis's first assesment and support Eva in accessing this care. As she desires to have surgery in Vancouver, I have completed the Vancouver program form and Form B. I have left these on Dr. Mattheis's desk. |
| SURGV | I have discussed | I have discussed vaginoplasty in full from the gp perspective and find that my patient is well informed and able to consent to surgery. |
| SW | Social Worker Note | |
| SWCP | POS SW Care Plan (calls SWCPTEXT) | |
| SWCPTEXT | POS SW Care Plan (TEXT ONLY) | Supportive Relationships (including family and others) Identified needs: «» Identified goals: «» Interventions/Steps: «» Substance Use Identified needs: «» Identified goals: «» Interventions/Steps: «» Mental Illness Identified needs: «» Identified goals: «» Interventions/Steps: «» Behavioral Issues (including aggression) Identified needs: «» Identified goals: «» Interventions/Steps (including safety plan): «» Health & Health service needs (level of health system engagement & service intensity required) Identified needs: «» Identified goals: «» Interventions/Steps: «» Crisis response needs Identified needs: «» Identified goals: «» Interventions/Steps: «» Housing Identified needs: «» Identified goals: «» Interventions/Steps: «» Criminal justice involvement Identified needs: «» Identified goals: «» Interventions/Steps: «» Involvement with Ministry of Children and Families Identified needs: «» Identified goals: «» Interventions/Steps: «» Income—Financial/MSP insurance Identified needs: «» Identified goals: «» Interventions/Steps: «» Home/daily living activities (food, laundry, cleaning/hoarding) Identified needs: «» Identified goals: «» Interventions/Steps: «» Employment/Education/specialized knowledge Identified needs: «» Identified goals: «» Interventions/Steps: «» Wellness/Health/Leisure/Recreational Identified needs: «» Identified goals: «» Interventions/Steps: «» |
| SWI | VCH: Template - Substance Use: Signs of WD/Intox'n (AccelEMR) | Signs of Withdrawal or Intoxication Signs of Opiod WithdrawalSigns of Opiod IntoxicationSigns of Stimulant Intoxicantion [ «» ] None [ «» ] Craving [ «» ] Diarrhea [ «» ] Rhinorrhea [ «» ] Yawning [ «» ] Diaphoresis[ «» ] Goosebumps [ «» ] Myalgia [ «» ] Nausea [ «» ] Vomiting [ «» ] Anxiety[ «» ] Slurred Speech [ «» ] Pinpoint Pupils [ «» ] Poor Concentration [ «» ] Sleeping in waiting area [ «» ] Nodding off if not stimulated [ «» ] Drowsy[ «» ] Agitation [ «» ] Irritable [ «» ] Pressured speech [ «» ] Restlessness [ «» ] Large pupils [ «» ] Paranoia / Delusional |
| SWO | Social Work: Outreach | |
| SYPH | Doctor Syphilis | Clinical Information Date tested: «» TP EIA: «» RPR: «» TPPA: «» Most Recent Syphilis serology: «» HIV status: «» HIV PrEP: «» Dx: «» Treatment order: «» Partner notification: «» Recommendations HIV PrEP: «» Repeat syphilis serology every 3-6 months Test for Chlamydia and Gonorrhea Assess if the patient has given birth to any children, and consider whether the children should be tested as well. Do pregnancy test (if patient able to get pregnant and ≤ 50 years old) Offer TP PCR swabs from throat/rectum/vagina to help with staging If there is any pertinent clinical information that may modify the above staging and management, please contact the BCCDC syphilis physicians for further guidance |
| SYPHCONTACT | Client is a contact to syphilis | Client is a contact to syphilis. Please order Syphilis bloodwork (T. pallidum EIA) and, Treat as a contact to syphilis with <> <>. <> << Instruct client to abstain from all sexual contact for 14 days from the start of treatment>> The medication can be ordered for free through the BCCDC Pharmacy by submitting a request on the STI drug order form which can be accessed through the BCCDC website. If you have any questions you can contact a BCCDC physician at 604-707-5610 or a syphilis case management nurse at 604-707-5607. |
| SYPHFP | Syphilis False Positive | Syphilis serology appears consistent with false positive result. Repeat serology needed to confirm. |
| SYPHFU | Syphilis Follow Up (Calls SYPHFUTEXT) | |
| SYPHFUTEXT | Syphilis Follow Up (Text Only) | HIM Clinic RNs to use this typing template for positive Syphilis results in addition to \stit: Number of partners in traceback period? «» Gender of partners? «» Do any partners have birthing capacity?«» Review testing/treatment of partners with case per BCCDC recommended trace back period (Less than 3 months, test and treat; More than 3 months, test only) «» Partner notification: Case will contact partners «» OR, VCH CD/BCCDC to assist with partner notification «» Review symptoms for neuro syph «»; If symptomatic, describe symptoms «» Review vaccine eligibility (HPV, Mpox, HAV, HBV) «» HIM Clinic RN to task VCH CD (if VCH resident) or BCCDC (if non-VCH resident) to refer case for additional public health follow-up «» If case or partner(s) are pregnant or have birthing capacity If case needs assistance in notifying partners If case has neurological symptoms |
| SYPHPRE | Prenatal Syphilis | Prenatal Syphilis Positive. Copy to Clinic Physician |
| T2DM | Open Type 2 Diabetes Management Form | |
| TC1 | First Phone Call to Client | «Letter.Letter.Today»: 1st call |
| TCBREF | TCB Referral Note: Post-Operative Nursing Support | TCB Referral Note: Post-Operative Nursing Support General Information: • Family practitioner (MD/NP): «» • Involved clinicians (ie. counseling): «» • Support persons involved in care (emergency contact): «» Contact information: «» • Client's preferred method of communication: «» Okay to leave detailed message? Flight Information: • Departing flight: «» • Return flight: «» • Hope air referral pending?: «Y/N» • Any client indicated needs for travel arrangements?: «Y/N» • Details: «» Surgery: • Previous gender-affirming lower surgeries to date: Where: When: Complications?: Gender affirming surgery (type): «» • Surgical Date: «» Pre-op date: Post-op date: Surgical package received?: • Surgeon: «» • Location: «» • Contact information: «» • after care plan? : «» Specialist Follow up: • Specialist referrals (in place): «Y/N» • Specialist: «» • Consultation done?: «Y/N» • Consult notes available for review by Nurse in EMR Profile? «Y/N» • Post-operative follow up?: «Y/N» Appointment Date/Time: «» • Specialist contact information for Clinician consult: «» |
| TCL | VCH- NURS43 and opens Insite Safe Supply New Checklist | |
| TELEPREP | TelePrEP | Client contacted clinic requesting access to PrEP through Tele-PrEP Program Reason for request and referral source: Located in: «» HIRI Score Completed Reviewed Basic PrEP Info, Tele-PrEP Process and obtained verbal consent for Virtual Care E-mail sent to «»client e-mail«» with Baseline lab requisition, PrEP Patient Info, Virtual Care Client Notification Form Virtual PrEP Appt booked: «» Enrolled in Memora |
| TEST | fluids panadol or panadeine | fluids panadol or panadeine for pain / discomfort saline nasal spray from the chemist use 5-10 times a day - helps clear the sinus rest if sicker , not improving , worried , return to doctor |
| TEXT | Text Encounter | |
| TFWA | TFW Baseline Health Assessment | Arrival date: «Letter.Letter.Today» Seasons in Canada:«» Allergies: «» City/Country: «» Cases (in region): «Y/N» Are you well today?: «Y/N» Do you have any chronic health conditions such as diabetes, hypertension, or asthma?: «Y/N» If yes, what are they: «» Are you taking any medication?: «Y/N» If yes, please list your medications (include name, dosage and frequency): «» Do you smoke?: «Y/N» If yes, how many cigarettes do you smoke every day?: «» If yes, did you bring tobacco with you for the next 14 days? «Y/N» Do you drink alcohol?: «Y/N» If yes, how many drinks per week? «» One drink of alcohol includes one glass of beer, one small glass of wine or one shot of hard alcohol Follow up: «» |
| TFWS | TFW Symptom Tracker | |
| TIC | Testosterone Informed | Testosterone Informed Consent: Permanence including: Hair growth/balding «» Voice changes «» Genital changes «» Acne scars «» Fertility (possible) «» Impermanence including: Muscle/fat distribution «» Menstrual cessation including risk of pregnancy (variable) «» Mood/energy changes «» Libido/sexuality changes «» Skin changes (oil,acne) «» Genital dryness/irritation «» Weight changes «» Likely risk of: Polycythemia «» Sleep apnea «» Possible risk of (with other risk factors): Lipid changes, diabetes «» Liver inflammation «» Cardiovascular risk «» Increased blood pressure «» Other: Off label/limited long term studies «» Risk of regret «» |
| TNA | TiOAT Nursing Assessment (calls TNATEXT) | |
| TNATEXT | TiOAT Nursing Assessment (TEXT ONLY) | TiOAT Nursing Assessment S: - Last drug use and amount «» - Last alcohol use and amount «» O: - General appearance (i.e. does the participant look «unwell, well, dishevelled, etc» - Level of consciousness («Alert/Drowsy») If drowsy, document «spO2, PR, RR» - Breath rate («normal/abnormal») - Pupil size («normal/pinpoint») - Smell of alcohol («yes/no») - Slurred speech («yes/no») A: - Dose received for witness ingestion («yes/no») - Route of consumption («PO/IV/IM/Snort») - Dose tolerated well («yes/no») - If no, document description «» P: - Dose dispensed as carries («yes/no») - Dose and time participant can return for next dose «» - Any follow up required «» |
| TNI | TiOAT Nursing Intake (calls TNITEXT) | |
| TNITEXT | TiOAT Nursing Intake (TEXT ONLY) | Treatment Nursing Intake Assessment Substance History Substance(s) currently using: «» How many overdose have you had: «» In the last month: «» in the last 6 months: «» Do you have a THN kit («Y/N») o Offer THN and provide education Are you on OAT program currently? («Y/N») If no, have you ever been on OAT in the past? («Y/N») Medical History Are you receiving primary care: («Y/N») If yes, Primary care physician: «» Other Team involved in care (ie. ACT, OOT, STOP, ICMT): «» Medical and/or Mental Health Condition/co-morbidities: «» Pharmacy: «» Allergies: «» Clinical Signs/Symptoms of substance withdrawal: «» Signs/Symptoms of sedation: «» To Do: o Vitals: «BP_, RR_, PR_, Temp_, sO2_» o PharmaNet Review: «» o CareConnect Review: «» o UDS result: «» o Pregnancy Test (for those who can conceive) o HIV/STI/HCV testing o Collect pending bloodwork Social Status Housing Status: «Apt/House, SRO, Shelter: , NFA, Other: » Financial Income source: «Employed, PWD, Social Assistance, Other: » Client Priorities and Goals What are your short-term goals: «» What are your long-term goals: «» Plans/Strategies to achieve goals: «» Signed Agreement and Consent Orientation Form: («Y/N») Program consent: («Y/N») |
| TOB1 | Tobacco Intake | Break Free (Tobacco group Intake) Start Date:«» 1. Home phone number and address: «» 2. Primary Health care provider: «» 3. Do you access services from VCH addictions or mental health teams? «» 4. If female are you pregnant or breastfeeding? «» 5. How much do you smoke? «» 6. Pack/year history: «» (#cigs per day) *«» (# years smoked) divided by 20=«» 7. Do you smoke marijuana/how much? «» 8. Have you tried to quit before? «» 9. How long did you quit for? «» 10. Have you used nicotine replacement therapy or medications to help you quit smoking? «» If so what did you use and for how long?«» 11. Do you have any medical conditions? «» What? «» 12. Are you on any medications? «» What?«» 13. Do you have any drug allergies? «» 14. Do you have a psychiatric disorder history? «» What? «» 15. Do you have any past self-harm or suicidality history? «» When? «» 16. Any substance use disorder history? «» What and how often. «» If client is clean for how long? «» 17. CO level: «» When was your last cigarette? «» 18. Fagerstrom score= «» 19. PHQ-2= «» Treatment Plan: «» Give start of Break Free program reminder slip. |
| TOVIEWRF | PSP-MSK - Low Back Pain - Red Flags (AccelEMR) | [ «» ] Neurological: motor or sensory loss, progressive neurological defects, cauda equina syndrome [ «» ] Infection: fever, IV drug use, immune suppressed (eg. steroid use) [ «» ] Fracture: trauma, osteoporosis risk [ «» ] Tumor: history of cancer, unexplained weight loss, significant unexpected night pain, severe fatigue [ «» ] Inflammation: onset > 3 months ago, age < 45, morning stiffness > 30min, improvement with exercise, disproportionate night pain [ «» ] No red flags |
| TOVIEWYF | PSP-MSK - Low Back Pain - Yellow Flags (AccelEMR) | [ «» ] Belief that pain and activity will cause physical harm [ «» ] Problems at work, poor job satisfaction [ «» ] Excessive reliance on rest, time off work or dependency on others [ «» ] Unsupportive/dysfunctional or dependent family relationships [ «» ] Persistent low or negative moods, social withdrawal [ «» ] Over exaggeration/catastrophyzing of pain symptoms [ «» ] Belief that passive treatment (modalities) is key to recovery [ «» ] No yellow flags |
| TPI | TiOAT Physician Intake | TiOAT/iOAT hx: «» Substance use hx: «» Opioids - «» Date of first use - «» timeline of route (oral, then smoked, then IV?) - «» current use «» every daily? «» Overdoses? «» Methadone - «» Bup - «» SROM - «» How did you do on each of these medications? «» Benzodiazepines prescribed vs. Illicit - «» date of first use - «» current use - «» ever daily? «» Hx of withdrawal seizures - «» Alcohol Date of first use - «» current use - «» Daily drinker now or in past? «» ? seizures - «» ? hospitalizations/detox - «» ? black outs - «» ? DUIs - «» Cocaine/crack date of first use - «» timeline of route - «» current use - «» ever daily? «» Crystal methamphetamine Date of first use - «» timeline of route - «» current use - «» ever daily? «» Nicotine date of first use - «» current use - «» ever daily? «» Cannabis date of first use - «» current use - «» ever daily? «» Ecstasy/GHB/LSD/PCP date of first use - «» current use - «» ever daily? «» Detox/Residential Tx - «» longest abstinence? «» PMHx: Social Hx: «» Incarceration? «» Housing? «» Money - «» Relationships in life? «» Current Supports? «» Goals for treatment: «» Medications: «» Allergies: «» Physical exam: «» UDS: «» Track marks: «» A/P: «» Severe OUD: This person meetings criteria for iOAT/TiOAT. They have ongoing illicit opioid use and are at high risk of overdose death. We have reviewed the benefits/risks of this treatment and the off label use a tablet for injection purposes. The nurses have reviewed the need to use a filter/sterile injection technique in order to decrease risk of infection. Health Canada and the Ministry of Health has supported this treatment in the context of the overdose crisis. We have offered OAT in conjunction with TiOAT. |
| TPVD | Turning Point Vancouver-Discharge Note | |
| TPVF | Turning Point Vancouver-Follow | |
| TPVI | Turning Point Vancouver-Intake Assessment | |
| TRAAC | Team Request for AAC Support (calls TRAACTEXT) | |
| TRAACTEXT | Team Request for AAC Support (TEXT ONLY) | Problem:«» Requested Action/Plan (include alternative recommendations if AAC is unable to make contact):«» Diagnosis: «» Is Client aware of request for support: «Yes/No» Extended Leave: «Yes/No/Previous» Medications: «» Presentation when well: «» Presentation when unwell: «» Substance Use: «» Risk: Suicide: «» Violence: «» Last Hospitalization (Date/Hospital): «» Alternate Support Person (Name/Contact #): «» Client Physical Description: «» |
| TRANS | TSC Nursing Intake (calls TRANSTEXT) | |
| TRANSTEXT | TSC Nursing Intake (TEXT only) | «In person visit at 3 Bridges» «Video visit – Client located in BC?» «Confirm client address – care planning and redirection if located outside VCH catchment» Subjective: Name: «» Pronouns: «» Primary Care Provider: «» MSP/Extended health benefits: «» Preferred Pharmacy: «» ISI (also enter this information using isi \): Do you wish to identify as Indigenous? «Y/N» If yes: Do you identify as First Nations, Métis and/or Inuit? «Y/N» Goals of care with Trans Specialty Care Program «hormone goals, surgical goals, other support needs» Is this the first time you’re accessing gender affirming care? «» Gender History & Gender Affirming Steps Can you tell me a little bit about your gender identity? «» When did you first know this about yourself? «» Has this changed over time? If so, how? «» What gender affirming steps have you taken (and timelines)? «» What are the things you do that help you feel you’re living in your gender? «» Personal History: Employment/school: «» Education: «» Housing: «» Supports: «» Protective factors: «strengths, hobbies, interests, things that bring you joy» Medical History: Collateral review: current Pharmanet (meds\ and confirm with client); TSC referral or self-referral form; brief review last 2 years in Care Connect & EMR; PARIS Quick View as needed. Current (diagnoses & chronic/ongoing health issues): 1. «» 2. «» Migraines: «» Blood clots/strokes: «» Sleep apnea: «» Hospitalizations: «» Surgeries (approx. date/age): «» Problems with anesthesia: «» Medications: «including supplements (Biotin), vitamins, OTC meds taken regularly, and mental health medications» Allergies (Add to Adverse Reactions): «» Family Health Hx: (if known) (heart attack, stroke, blood clots, HTN, high cholesterol, diabetes, cancer, liver or kidney problems, autoimmune ds, asthma/resp ds, genetic conditions) Mo: «» Fa: «» Bro: «» Sis: «» M. Granfa: «» M. Grandmo: «» P. Grandfa: «» P. Grandmo: «» Mental Health History: Depression/anxiety: «» Other mental health dx/ neurodivergence? «including ADHD, autism, bipolar, schizophrenia, eating disorder» Thoughts of self-harm/suicidal ideation: «» Supports: «e.g. counsellors, MH team» Present mental health stability: «» Substance Use: (frequency, amount, route) Tobacco/nicotine: «» Alcohol: «» Cannabis: «» Other substances: «» Sexual Health: While you’re part of this clinic, we can also talk about sexual health needs, vaccines and contraception. Is this something you’d like to talk about today? «» «If yes can refer to Get Checked Online OR offer to add STI testing to baseline bloodwork» «Address pressing concerns PRN, also will be asked as part of regular hormone follow up care» Hormone Goals & Considerations: What effects/outcomes are you most looking forward to from hormones? «» Concerns/ are there any effects that you don’t want? «» Anticipated challenges: «e.g. transportation, needlephobia, medication adherence, getting BW done regularly» Thoughts/feelings re: future fertility/desire for biological children: «» «Look at TCBC website; orient to Effects and Risks sections» Objective: «Mini-MSE – if anything remarkable» Ht «» Wt «» BP «» Assessment/Plan: « delete unneeded lines» Any possible issues/ areas of concern: «yes/no» (if yes see above highlighted in blue) Baseline bloodwork ordered: «see EMR Pathology “Trans feminizing” and “Trans masculinizing” Baseline under Sets» «If over 40 years old, BMI > 35 or strong family history of diabetes, high cholesterol, thyroid issues: add TSH, HgbA1C, Lipid profile (non-fasting)» « If taking Biotin supplement, hold for at least 6 hours before draw» 3) STI testing: «» 4) Hormone information reviewed on TCBC website: «yes/no (can include brief detail)» 5) Follow-up appt. booked with TSC MD/NP: «» 6) Resources emailed/shared via Jane App: «Families in Transition 2nd Edition» «Changing Keys» «Support groups/ TCBC Resource Directory» «TCBC self-injection guide» «2SLGBTQ+ low cost/sliding scale counseling resources (Expressive Wellness, Dragonstone, Grounding Stone, QMUNITY)» «2SLGBTQ+ local activities/groups list» «FTM/NON-B/AFAB British Columbia Facebook group» 7) Task sent to Peer Health Navigator: «PCP Attachment, Peer Support, Gender Journeys, Misc» 8) Task sent to TSC SW group for additional supports: «» 9) Referral sent to Olive Fertility: «» 10) ROI sent to PCP/ MH provider PRN: «» 11) Special Authority requested/Pharmacare registration reviewed with client: «only for adults starting on testosterone with Pharmacare coverage, eg. Fair Pharmacare, PWD, IA, PPMB, FNHA» |
| TS | Termination Summary/Final Note v2 | |
| TTF | Transcription to Follow | Transcription to follow. |
| TTSCE | TSC: Estrogen follow-up (calls TTSCETEXT) | |
| TTSCETEXT | TSC: Estrogen follow-up (TEXT ONLY) | Appointment type «In person», «Telephone visit – client aware of limitations» «Video visit – Client aware of limitations» Client located in «» Current hormone regimen and duration: «» Pharmanet search done: «» Subjective Physical Health/positive changes: «» Adverse side-effects: «» Health/Med updates: «» Mental health: «» Social supports: «» Social transition: «» Substances: Nicotine: «» Cannabis: «» Alcohol: «» Other substances: «» Outstanding gender goals: «» Preventative Health Vitamin D 1000IU daily? «» Sexual health: (STI screen, PrEP): «» Immunizations: HPV: «Letter.Patient.Macro.LASTHPVVAC» Mpox: «Letter.Patient.Macro.LASTSPOXVAC» Objective: Labs: Timing of labwork to dose: • Estrogen: «Letter.Patient.Macro.LASTESTR» • Testosterone: «Letter.Patient.Macro.LASTTESTO» • Potassium: «Letter.Patient.Macro.LASTPOT» • ALT: «Letter.Patient.Macro.LATESTALT» • Creatinine: «Letter.Patient.Macro.LATESTCREATINNE» • Prolactin: «Letter.Patient.Macro.LASTPROLACTIN» • Hemoglobin A1C: «Letter.Patient.Macro.LATESTA1C» • Hemoglobin: «Letter.Patient.Macro.LATESTHEMOGLOB» • Lipids: «Letter.Patient.Macro.LATESTLIPIDS» • BP «» Assessment: Gender incongruence - «» Plan: Discussed lab results and dosage with client. Time provided for questions or concerns. Estrogen dose: «» Blocker dose: «» Follow-up appointment: «» Pending interventions: «» Client has standing orders and is aware to complete labwork prior to next appointment. Shared care with (External FP/NP): «Letter.Patient.CareTeam("External GP/NP").FullName»,«Letter.Patient.CareTeam("External GP/NP").Fax» Note sent? «Y» «N» |
| TTSCT | TSC: Testosterone follow-up (calls TTSCTTEXT) | |
| TTSCTTEXT | TSC: Testosterone follow-up (TEXT ONLY) | Appointment type «In person», «Telephone Visit – Client aware of limitations», «Video visit – Client aware of limitations» Client located in «» Current hormone regimen and duration: «» Pharmanet search done: «» Subjective Physical Health/positive changes: «» Adverse side-effects: «» Health/Med updates: «» Mental health: «» Self injections: «» Social supports: «» Social transition: «» Substances: Nicotine: «» Cannabis: «» Alcohol: «» Other substances: «» Outstanding gender goals: «» Preventative Health Sexual health: (STI screen, PrEP): Contraception: «» Vitamin D 1000IU daily? «» Immunizations: HPV: «Letter.Patient.Macro.LASTHPVVAC» Mpox: «Letter.Patient.Macro.LASTSPOXVAC» Cervical Ca screening: HPV swab dates: «Letter.Patient.Macro.LASTHPV» Objective: Labs: Timing of labwork to dose: • Testosterone: «Letter.Patient.Macro.LASTTESTO» • Hgb: «Letter.Patient.Macro.LATESTHEMOGLOB» • ALT: «Letter.Patient.Macro.LATESTALT» • Hemoglobin A1C: «Letter.Patient.Macro.LATESTA1C» • Hemoglobin: «Letter.Patient.Macro.LATESTHEMOGLOB» • Lipids: «Letter.Patient.Macro.LATESTLIPIDS» BP «» Assessment: Gender incongruence - «» Plan: Discussed lab results and dosage with client. Time provided for questions or concerns. Testosterone dose (concentration, dose, volume): «» Follow-up appointment: «» Pending interventions: «» Client has standing orders and is aware to complete labwork prior to next appointment Shared care with (External FP/NP): «Letter.Patient.CareTeam("External GP/NP").FullName», «Letter.Patient.CareTeam("External GP/NP").Fax» Note sent? «Y» «N» |
| TV | Template - Telephone Visit (AccelEMR) | Telephone Visit - 14076 (or 14079 if CCP, MHP, COPD or EOL) - Initiated by: Provider [ «» ] Patient [ «» ] Subjective/Objective: Reason for call - «» «» Assessment/Plan: Follow up «Letter.Patient.Next Appointment.Date»«» «» |
| TX1 | Treated with Pen G | Treated with Benzathine penicillin G 2.4 million units IM in a single dose |
| TX3 | Treated with Pen G (3 weeks) | Treated with Benzathine penicillin G 2.4 million units IM administered weekly for three weeks (for a total of 7.2 million units). |
| UA | Template - Urine Dip (AccelEMR) | Urine Dip: Gluc: «neg» Ketone: «neg» SG: «» Blood: «neg» Prot: «neg» Nitrite: «neg» Leuk: «neg» (Recorded by: «initials») |
| UAU | Aubagio Treatment Start Date (calls UAUTEXT) | |
| UAUTEXT | Aubagio Treatment Start Date (TEXT ONLY) | Patient was discussed with MS 1:1 patient support program patient commenced on Aubagio on «Letter.Letter.Today». MS 1:1 will follow up with the patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UAZME | Alzheimer's Clinic Medical Exam | General appearance: unremarkable HEENT: unremarkable Cardiovascular: Regular rate and rhythm, no murmurs Pulmonary: Lungs are clear to auscultation bilaterally Abdomen: Soft and non-tender Extremities: No peripheral edema. No rash noted «» |
| UAZNE | Alzheimer's Clinic Neurologic Examination | Mental Status: Fully alert. Oriented to self, time, place, situation. Expressive and receptive language grossly intact. Repetition is normal Cranial Nerves: I: Smell is normal II: Pupils 4mm, normal direct and consensual pupillary response to light. Visual fields are normal. Optic discs are normal bilaterally III, IV, VI: Extraocular muscles are intact V: Facial sensation is normal bilaterally, V1-V3 VII: Smile is symmetric. Eye closure is normal bilaterally VIII: Hearing to finger rub is normal bilaterally CNIX: Soft palate elevates symmetrically XI: Sternocleidomastoids are normal bilaterally. Shoulder shrug is normal XII: Tongue is midline with no fasciculations. Tongue movement is normal Motor: Tone is normal in the upper and lower extremities. There is no cogwheeling. There is no spasticity in upper or lower extremities. There are no fasciculations or atrophy noted. Strength is normal throughout Reflexes: Reflexes are 2/4 throughout. There is no clonus. Toes are downgoing Sensory: Sensation is grossly intact to vibration and pinprick throughout. There is no Romberg sign Coordination: Finger-to-nose and heel-to-shin are normal bilaterally. Gait is normal. Posture, stance, step height, stride length, turn, and arm swing are normal. Tandem gait is normal |
| UBOT | Botox Injection | Patient was assessed in the UBC MS Clinic. Botox was prepared and administered by Dr. «». Pt is currently receiving Botox for «». |
| UCD19 | CD 19 Blood Work Monitoring | Pt is receiving monthly CD 19 blood work monitoring. Patient completed blood work on «Date». Writer reviewed results CD 19 cells remains <0.01 plan to repeat testing in 1 months time, emailed patient. Task set to follow up. |
| UCLA | Cladribine Treatment Start Date (call UCLATEXT) | |
| UCLATEXT | Cladribine Treatment Start Date (TEXT ONLY) | Patient was discussed with Adveva patient support program patient commenced on Mavenclad on «Letter.Letter.Today». Adveva will follow up with patient and send bloodwork reminders and advise the UBC MS Clinic Nursing Team of any concerns. |
| UCOG | CogEval (calls UCOGTEXT) | |
| UCOGTEXT | CogEval (TEXT ONLY) | Patient seen by nursing at request of neurologist for completion of cognition screening using CogEval (iPad/electronic version of processing speed test). Patient provided verbal consent to screening. Patients’ adjusted z- score on CogEval is «», which indicates or does not indicate impairment. Patient made aware of score, limitations of screening tool and provided with supportive counselling and education around MS and impact on cognition. Possible plans: - No follow-up indicated. - Neurologist made aware based on score indicating impairment. - Neurologist made aware based on score indicating significant decline from previous screening. - Based on patient report indicating functional consequence of cognitive limitations, referral made to OT. - Based on patient need for further supportive counselling and impact on cognitive limitations on social function or mood, referral made to SW. |
| UCOP | Copaxone Treatment Start Date (calls UCOPTEXT) | |
| UCOPTEXT | Copaxone Treatment Start Date (TEXT ONLY) | Patient was discussed with Shared Solutions patient support program patient commenced on Copaxone «» on «Letter.Letter.Today». Shared Solutions will follow up with the patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UDISC | Discharge from UBC MS Clinic | Patient was assessed at the UBC MS Clinic. Dr. «» has advised that the patient no longer requires care by the UBC MS Clinic. |
| UDMF | Dimethyl Fumarate Treatment Start Date | Patient was discussed with «» patient has commenced on Dimethyl Fumarate titration on «Date». «» will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UFAM | Fampyra Treatment Start Date (calls UFAMTEXT) | |
| UFAMTEXT | Fampyra Treatment Start Date (TEXT ONLY) | Patient was discussed with BiogenONE patient has commenced on Fampyra on «Letter.Letter.Today» BiogenONE will follow up with patient in 1 months time to assess the effectiveness of Fampyra and will update the UBC MS Clinic Nursing Team. |
| UFINGO | Fingolimod Treatment Start Date | Patient was discussed with the «» Program patient commenced on fingolimod on «Date» at a First Dose Observation Clinic. «» program will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UGBM | Post Lemtrada Anti-GBM (Goodpasture’s Disease) | Writer reviewed patient’s monthly blood work. Noted abnormalities in urine and blood work. Writer called patient to assess. Pt reports (increase fatigue, poor appetite, decreased urine production or concentrated urine, breathlessness and leg swelling). Case reviewed with Dr. XXXXX. Plan is to refer/treat with XXXX. Follow up scheduled for XXXX. Pt aware to contact clinic if any progression of symptoms. Educated on signs and symptoms to observe. Pt aware to report to the emergency if any concerns. s\ |
| UGIL | Gilenya Treatment Start Date (calls UGILTEXT) | |
| UGILTEXT | Gilenya Treatment Start Date (TEXT ONLY) | Patient was discussed with the Go Program patient commenced on therapy on «Letter.Letter.Today» at a Go for First Dose Observation Clinic. Go program will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UGLA | Glatect Treatment Start Date (calls UGLATEXT) | |
| UGLATEXT | Glatect Treatment Start Date (TEXT ONLY) | Patient was discussed with the Ally patient support program patient commenced on Glatect on «Letter.Letter.Today». Ally will follow up with the patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UINS | Insurance documents | Writer received «» insurance documents . Left for Dr. «» to review and complete. |
| UITP | Post Lemtrada Immune Thrombocytopenia | Writer reviewed patient’s monthly blood work. Noted abnormalities with high probability of ITP WBC XXXX, RBC XXXX, platelets XXXX. Writer called patient to assess for active ITP. Pt is experiencing (increased fatigue, easy or excessive bruising, petechiae (reddish-purple spots under the skin that may appear as rash), bleeding from gums/nose, blood in urine/stool, heavy menstrual flow). Pt instructed to implement appropriate health hygiene frequent hand washing, masking as appropriate, light brushing of teeth, lightly clearing nasal passage. Dr. XXXX aware. Plan to continue monitoring monthly blood work. Referral to XXX submitted. Treatment provided XXXXXX. Follow up scheduled for XXXX. Pt aware to contact clinic if any progression of symptoms. Educated on signs and symptoms to observe. Pt aware to report to the emergency if any concerns. s\ |
| ULEM | Lemtrada Cycle 1 Planning | Lemtrada Nursing team advised by Dr. «» that they would like the patient to receive Lemtrada. BC Special Authority completed and submitted electronically. Patient consent obtained and the enrolment was completed. Left for the clerical team to faxed to MS 1:1. Lemtrada nursing orientation scheduled for «Date». Patient was emailed a lab requisition and advised to complete the necessary pre-screening. Pt was also instructed to arrange a PAP test through her GP. Task set to follow up and will review weekly with the MS 1:1 program. |
| ULEM48 | Completion of 48 mth post Lemtrada Blood Work(calls ULEM48TEXT) | |
| ULEM48TEXT | Completion of 48 month post Lemtrada Blood Work (TEXT ONLY) | Received notification from MS 1:1 that patient has successfully completed 48 month blood work monitoring post Lemtrada infusion. Pt has been discharged from the MS 1:1 patient support program. A notification of completion from the Lab watch program, history of all adverse events, and summary of blood work have been uploaded to the EMR. Dr. «Name» has be informed. No further concerns. Pt will now be followed by the MS Clinic nursing team. |
| ULEMABW | Abnormal Lemtrada Monthly Blood Work (calls ULEMABWTEXT) | |
| ULEMABWTEXT | Abnormal Lemtrada Monthly Blood Work (TEXT ONLY) | Received notification from MS 1:1 that patient has successfully completed monthly Lemtrada blood work monitoring. Abnormalities noted. Patient assessment completed. Dr. «Name» informed. Will continue to monitor. |
| ULEMBW | Normal Lemtrada Monthly Blood Work (calls ULEMBWTEXT) | |
| ULEMBWP | Lemtrada Monitoring Past Due | MS 1:1 has advised that patient is past due on Lemtrada monitoring. Last completed on «Date». Writer called patient to remind patient of the importance of regular monitoring. Task set for follow up. |
| ULEMBWTEXT | Normal Lemtrada Monthly Blood Work (TEXT ONLY) | Received notification from MS 1:1 that patient has successfully completed monthly Lemtrada blood work monitoring. No abnormalities noted. Dr. «Name» aware. |
| ULEMED | Lemtrada Education Session | Pt was assessed virtually on the phone/zoom. Writer reviewed the medication Lemtrada (required pre-screening, route of administration, side effects, MS 1:1 patient support program). Pt expressed concerns about «». Follow up tasks set. Will review weekly with the MS 1:1 program. |
| ULP | Lumbar Puncture Education (calls ULPTEXT) | |
| ULPTEXT | Lumbar Puncture Education (TEXT ONLY) | Writer contacted patient & reviewed pre-screening blood work all within normal limits. Patient is not taking any blood thinners at present. Patient’s medication have not changed. Pt has no known allergies. Reviewed lumbar puncture education & procedure. Pt aware to arrive with an accompanied adult, will pre-hydrate with fluid. Reviewed patients questions and concerns. No further follow up required. |
| UMED | Usual Medication List | Usual Medication List «Letter.Patient.UsualMedicationRxSig» |
| UMSCOMPASS | Patient was discussed with | Patient was discussed with <<>>. Pt commenced on therapy <<>>. COMPASS program will advise UBC MS RN Team if any adverse events. |
| UMSICAMMS | This patient participated in | This patient participated in the iCAMMS trial, which was an open-label study of alemtuzumab/Lemtrada in MS patients. Their first dose of Lemtrada was , and their last dose was . |
| UMSMASSAGE | To Massage Therapy: | To Massage Therapy: Please evaluate and treat this patient who has multiple sclerosis related spasticity and would benefit from massage therapy. Sincerely, |
| UMSOCR | Work/School letter for OCR | To Whom It May Concern: My patient is undergoing a medical treatment for a neurologic disease. The treatment involves 2 days of infusion at a specialized clinic, spaced 2 weeks apart. Following each treatment, the patient may need up to 3 days to recover from the treatment. I would appreciate your providing all reasonable accommodations so that my patient can appropriately manage their disease. Yours sincerely, |
| UMSOT | To: Occupational therapy | To: Occupational therapy Please evaluate and treat this patient for Sincerely, |
| UMSPT | To: Physical therapy | To: Physical therapy Please evaluate and treat this patient for imbalance and leg weakness with frequent falls due to multiple sclerosis. |
| UMSTECTSD | Tecfidera TSD | Pt was discussed with BiogenONE commenced on Tecfidera on April 15, 2018. BiogenONE will advise MS Clinic Nursing Team of any adverse events. |
| UMSTRIAL | UMS - MS and NMO Clinical Trials Referral | UMS - MS and NMO Clinical Trials Referral Has pt consented to contact? «Y/N» Study and Level of Urgency: «» Referring Provider: «Letter.LoggedOnUser.FullName» Patient Name:«Letter.Patient.FullName», DOB: «Letter.Patient.DateOfBirth», Age: «Letter.Patient.Age», PHN: «Letter.Patient.NHI_Number» Current Diagnosis: «Letter.Patient.Macro.LASTUMSDIAG» Medications Documented in EMR: «Letter.Patient.UsualMedicationRxSig» Last Relapse (MMM-YYYY): «Letter.Patient.Macro.RELDATE» EDSS: «Letter.Patient.Macro.LASTEDSS», «Letter.Patient.Macro.LASTEDSSDATE» Additional Details (refer to Enrolling Trials binder) |
| UNDGE | Newly Diagnosed Group Education (calls UNDGETEXT) | |
| UNDGETEXT | Newly Diagnosed Group Education (TEXT ONLY) | Client attended newly diagnosed group education session. Session led by nurse, physiotherapist and occupational therapist and was delivered using virtual health over zoom, lasting 60 minutes on «Letter.Letter.Today». Purpose of group session is to introduce new clients to role of various team members in addition to providing foundational education around MS and importance of managing new diagnosis, fatigue and exercise. Roles of nursing, physiotherapy and occupational therapy outlined, including when and how to self-refer for access. Education provided around the following topics: MS symptoms, managing relapses, wellness, benefits of exercise, goal setting, resources for exercise, fatigue facts, importance of rest, pacing, reducing energy demands of daily activities and resources to support self-management. Client encouraged to book individual appointment with nursing, PT and/or OT as needed. Denise Kendrick OT, Michelle McCarthy PT, Donna Kuipers RN, Megan Beaton RN, Aileen DeLeon RN |
| UODAT | Ocrevus Infusion Dates (calls UODATTEXT) | |
| UODATTEXT | Ocrevus Infusion Dates (TEXT ONLY) | Pt was discussed with the compass program and is tentatively scheduled to commence on Ocrevus «Letter.Letter.Today» at «». Compass will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UODOC | Ocrevus Insurance Documents (calls UODOCTEXT) | |
| UODOCTEXT | Ocrevus Insurance Documents (TEXT ONLY) | Writer received «» insurance documents. Completed and left for Dr. «» to sign. |
| UOFA | Kesimpta Treatment Start Date (calls UOFATEXT) | |
| UOFABW | Kesimpta Blood Work | Patient commenced on Kesimpta «» and is due for repeat blood work in 6 months. Lab requisition sent to patient. Task set for follow up. |
| UOFATEXT | Kesimpta Treatment Start Date (TEXT ONLY) | Pt was discussed with the Go Program. Pt commenced on Kesimpta (Ofatumumab) titration schedule on «insert date». Plan to transition to monthly injections as per protocol. Pt will follow up with the Go Program for any concerns. |
| UREB | Rebif Treatment Start Date (calls UREBTEXT) | |
| UREBTEXT | Rebif Treatment Start Date (TEXT ONLY) | Patient was discussed with Adveva patient support program patient commenced on Rebif on «Letter.Letter.Today». Adveva will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| URINE | Urine Dip template | Urine Dip Glucose «» Protein «» PH «» Ketones «» Leukocytes «» Nitrate «» Blood «» Haemoglobin «» |
| URIT | Rituximab Infusion Dates (calls URITTEXT) | |
| URITTEXT | Rituximab Infusion Dates (TEXT ONLY) | Pt was discussed with Jointeffort pt has been tentatively scheduled for «Letter.Letter.Today» at «». Jointeffort will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| URUX | Rituximab Infusion Dates (calls URUXTEXT) | |
| URUXTEXT | Rituximab Infusion Dates (TEXT ONLY) | Pt was discussed with Pfizer Flex pt has been tentatively scheduled for «». Pfizer Flex will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns |
| US | Radiology Template - U/S-General (AccelEMR) | RELEVANT HISTORY/REASON FOR EXAM: «» BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| USAT | Satraluzimab Treatment Start Date (calls USATTEXT) | |
| USATTEXT | Satraluzimab Treatment Start Date (TEXT ONLY) | Pt was discussed with Compass program and commenced on Satraluzimab on «Letter.Letter.Today». Compass will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| USB | Radiology Template - U/S-Biopsy (AccelEMR) | LOCATION: «» RELEVANT HISTORY/REASON FOR EXAM: «» LAB FOR INTERVENTIONAL PROCEDURE ORDERED: [ «» ] (Ordering Provider - See Lab Set "Imaging...") BOOKING INFORMATION: Elective [ «» ]; Urgent* - today [ «» ], OR within [ «» ] [ «» ] Patient NOT available for an appointment - When not available:_________________ [ «» ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| USD | Template - Radiology- Urgent Same Day Appointment (AccelEMR) | Radiologist to call Dr.__________ on cell phone @ ____________ |
| USDMT | SDMT (calls USDMTTEXT) | |
| USDMTTEXT | SDMT (TEXT ONLY) | Patient seen by nursing at request of neurologist for completion of cognition screening using Symbol Digit Modalities Test (SDMT) oral version. Oral version of SDMT completed as patient indicated hand/upper extremity dysfunction. Patient provided verbal consent to screening. Patients’ raw score on SDMT is «», which indicates or does not indicate impairment. Patient made aware of score, limitations of screening tool and provided with supportive counselling and education around MS and impact on cognition. Possible plans: - No follow-up indicated. - Neurologist made aware based on score indicating impairment. - Neurologist made aware based on score indicating significant decline from previous screening. - Based on patient report indicating functional consequence of cognitive limitations, referral made to OT. - Based on patient need for further supportive counselling and impact on cognitive limitations on social function or mood, referral made to SW. |
| USIP | Siponimod Treatment Start Date | Patient was discussed with the Go Program patient commenced on therapy with Siponimod on «Date». Go program will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. Task set for follow up on blood work q 3 months. |
| USL | Radiology Template - U/S-Leg (AccelEMR) | RELEVANT HISTORY/REASON FOR EXAM: D-dimer - «»; «» BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| USO | Radiology Template - U/S-Obstetrical (AccelEMR) | RELEVANT HISTORY/REASON FOR EXAM: LMP: «»; «» BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| USR | USR | TCB - Added to USR. |
| USRC | Completed upper surgery referral | The referral for upper surgery is complete and we have added your patient to the central waitlist. Trans Care BC will contact the patient to discuss their surgeon of choice. No further follow up from the referring provider is required. |
| USRIC | Incomplete upper surgery referral | Action Required: The referral for upper surgery is incomplete. Please provide the following information: «» «» Once we have this information, we will add your patient to the central waitlist. |
| USS | Radiology Template - U/S-Soft Tissue (AccelEMR) | ANATOMICAL AREA: «» RELEVANT HISTORY/REASON FOR EXAM: «» BOOKING INFORMATION: Elective [ ]; Urgent* - today [ ], OR within [ ] [ ] Patient NOT available for an appointment - When not available:_________________ [ ] Patient available on short notice *Note to Imaging Dept/Clinic re URGENT requests Only: - Inform clinic if you are not able to meet the above timeframes. - If more information is required, please have the Radiologist call the ordering physician at the following cell number: - If requested within 2 days, please call the clinic to confirm receipt of this fax. |
| UTEC | Tecfidera Treatment Start Date (calls UTECTEXT) | |
| UTECTEXT | Tecfidera Treatment Start Date (TEXT ONLY) | Patient was discussed with BiogenONE patient has commenced on Tecfidera titration on «Letter.Letter.Today». Patient has been enrolled into the BiogenONE Lab Assist + Program for bloodwork monitoring. BiogenONE will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UTERI | Teriflunomide Treatment Start Date | Patient was discussed with «» patient support program patient commenced on teriflunomide on «Date». «» will follow up with the patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| UTHY | Post Lemtrada Thyroid Disorder | Writer reviewed patient’s monthly blood work. Noted abnormalities in blood work. Writer called patient to assess. Pt reports (increase fatigue, weight gain, muscle cramping, constipation, brain fog). Case reviewed with Dr. XXXXX. Plan is to refer/treat with XXXX. Follow up scheduled for XXXX. Pt aware to contact clinic if any progression of symptoms. Educated on signs and symptoms to observe. Pt aware to report to the emergency if any concerns. s\ |
| UXPO | Rituximab infusion dates (calls UXPOTEXT) | |
| UXPOTEXT | Rituximab infusion dates (TEXT ONLY) | Pt was discussed with Xpose pt has been tentatively scheduled for «Letter.Letter.Today» at «». Xpose will follow up with patient and advise the UBC MS Clinic Nursing Team of any concerns. |
| V | Vitamin D | I suggest the patient take high dose of vitamin D3, 2-5,000/day. |
| VA | Template - Visual Acuity (AccelEMR) | Visual Acuity: Right Left Both Corrected 20/«» 20/«» 20/«» Uncorrected 20/«» 20/«» 20/«» (Recorded by: «initials») |
| VC | Opens Virtual Care form | |
| VCHCD | VCH CD follow-up | |
| VCHCDS | VCH CD syphilis follow-up | |
| VCHLSUD | Latent Syphilis of Unknown Duration | Client specific order by «Dr. Althea Hayden MSP#66339»«Dr Rohit Vijh MSP# 58044»: -Latent Syphilis of Unknown Duration (LSUD) -At initial clinic visit, offer oral syphilis NAT PCR swab plus Bicillin® L-A -Await syphilis PCR swab results -If syphilis PCR is negative, continue with 2nd and 3rd doses of Bicillin® L-A as originally ordered -If syphilis PCR is positive, CD nurse to review with BCCDC STI physician for re-staging and updated treatment recommendations |
| VCHWMD | South Vancouver Withdrawal Management - Discharge Note | |
| VCHWMF | VCH Withdrawal Management - Follow Up | |
| VCHWMI | VCH Withdrawal Management | |
| VCS | Virtual Care Setup (calls VCSTEXT) | |
| VCSTEXT | Virtual Care Setup (TEXT ONLY) | 1) Client phone number in EMR - «Letter.Patient.PreferredPhoneNumber» 2) Client email address in EMR? - «» 3) Client verbal consent given - «» 4) Preferred platform (eg. telephone, zoom, Skype, etc)? - «» Recommended consent statement: “Just like online shopping or email, Virtual Care has some inherent privacy and security risks that your health information may be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed. In order to improve privacy and confidentiality, you should also take steps to participate in this virtual care encounter in a private setting and should not use an employer’s or someone else’s computer/device as they may be able to access your information. If you want more information, we can direct you to the appropriate resources. If it is determined you require a physical exam you may still need to be assessed in person. You should also understand that virtual care is not a substitute for attending the Emergency Department if urgent care is needed. Are you ok to continue?” |
| VDCD | Vancouver Detox - Discharge Note | |
| VDCF | Vancouver Detox Follow-Up | |
| VDCI | Vancouver Detox - Intake Assessment | |
| VIDEO | Video Encounter | |
| VRN | Vocational Rehab Note | |
| WAD | PSP-MSK - Low Back Pain - Waddell Signs (AccelEMR) | Waddell Signs – Nonorganic Physical Signs in Low Back Pain These can be used to screen individuals who require detailed psychological assessment (does NOT indicate malingering) Scoring: Any sign counts as positive for that type; 3 or more types positive = clinically significant [ «» ] Tenderness tests: superficial and diffuse tenderness and/or nonanatomic tenderness [ «» ] Simulation tests: movements which produce pain, without actually causing that movement, such as axial loading and pain on simulated rotation [ «» ] Distraction tests: recheck positive tests when the patient's attention is distracted, such as a straight leg raise test [ «» ] Local disturbance: regional weakness or sensory changes which deviate from accepted neuroanatomy [ «» ] Overreaction: subjective signs regarding the patient's demeanor and reaction to testing |
| WAX | Template - Ear Syringe (AccelEMR) | Patient presents for removal of impacted cerumen of «R or L or both» ears by irrigation. This was completed today without difficulty. Otoscopy by Dr. «name» now reveals clear external auditory canals with normal tympanic membrane. |
| WB | Template - Well Baby Visit (AccelEMR) | No concerns re hearing or vision. Normal developmental milestones. Diet and sleep normal. Immunizations up to date. |
| WBP | weekly dispense in blister | weekly dispense in blister pack |
| WBV | Template - Well Baby Measurements (AccelEMR) | Measurements: LENGTH «cm», WEIGHT «kg», HC «head circumference in cm» |
| WC | Template - Well Child Visit - Generic (AccelEMR) | WCV - age: «» «months/years» old History Here today with «mother» Parental concerns - «none» Developmental Milestones - «meeting milestones in all spheres» Diet - «Good variety and amounts of food» Immunizations - «up to date for age» Examination ENT «N» Resp «N» CV «N» Abd «N» GU «N» MSK «N» Integ «N» Neuro «N» Growth charts show «normal growth pattern» |
| WCB1 | Template - WCB - First Visit (AccelEMR) | WCB - First Visit (DOI - Date: «») - (bill MSP 13070 if manage a non WCB injury problem - document in a New Contact) Mechanism of Injury: «» Type of Work: «» Prior Problems Affecting Injury, Recovery and Disability: «» Initial Symptoms: «» Current Symptoms: «» Current Treatment: «» Current Physical and Psychological Restrictions: «» |
| WCB2 | Template - WCB - Follow-up (AccelEMR) | WCB - Follow up Visit (bill MSP 13070 if a non WCB injury problem is addressed - document in a New Contact) Current Symptoms: «» Current Treatment: «» Current Physical and Psychological Restrictions: «» |
| WCB3 | Template - WCB - Prior Problems (AccelEMR) | See Clinical Info: / Subjective: / Prior Problems Affecting Injury, Recovery and Disability: |
| WCB4 | Template - WCB - Current Phys and Psych Restriction (AccelEMR) | See Clinical Info: / Subjective: / Current Physical and Psychological Restrictions: |
| WCBS1 | Template (SOAP) - WCB - First Visit (AccelEMR) | WCB - First Visit (DOI - Date: «») - (bill MSP 13070 if manage a non WCB injury problem - document in a New Contact) Type of Work: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «» Mechanism of Injury: «» Prior Problems Affecting Injury, Recovery and Disability: «» Initial Symptoms: «» Current Symptoms: «» Current Treatment: «» Current Physical and Psychological Restrictions: «» Objective: «» Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date»«» «» |
| WCBS2 | Template (SOAP) - WCB - Follow Up (AccelEMR) | WCB - Follow up Visit (bill MSP 13070 if a non WCB injury problem is addressed - document in a New Contact) Current Symptoms: [Appt Reason - «Letter.Patient.Last Arrived Appointment.ApptType»; «Letter.Patient.Last Arrived Appointment.Reason»] [ Arrived - «Letter.Patient.Last Arrived Appointment.ArrivedAMPM»] «» Current Treatment: «» Current Physical and Psychological Restrictions: «» Objective: «» Assessment & Plan: Follow up «Letter.Patient.Next Appointment.Date»«» «» |
| WCV | Template - Well Child Visit (> 18 months) (AccelEMR) | Well Child Visit Measures: Length «cm»; Weight «kg» |
| WE | Template - Wedge excision and nail bed ablation (AccelEMR) | 3 cc of 2% xylocaine without epi. Wedge excision and nail bed ablation of «» aspect of «» great toe with 10% NaOH for 1 min. Neutralized with Acetic Acid. Post Op instructions given to pt. (13633) |
| WMNA | Vancouver Community Withdrawal Management Nurs (Calls WMNATEXT) | |
| WMNATEXT | Vancouver Community Withdrawal Management Nurs (TEXT ONLY) | Reason for admission: Presentation on intake: Substance Use: Goals: Current OAT: History of withdrawal complications: Any relevant medical history: Any relevant Psychiatric History: Risk assessment: Connection to ongoing care: OAT prescriber/GP: Community teams: Referrals already in place: Pharmacy: Plan: |
| WMND | Vancouver Community Withdrawal Management Nu (Calls WMNDTEXT) | |
| WMNDTEXT | Vancouver Community Withdrawal Management Nursing (TEXT ONLY) | Reason for admission: Reason for Discharge (Planned/Unplanned/Goals met): Specific Discharge Destination: Current Medications/OAT: Pharmacy where discharge prescription was faxed: Complications during their stay: Any other relevant information that occurred during their stay: Risk Assessment Connection to ongoing care OAT prescriber/GP: Community teams: Referrals in place: Pharmacy: |
| WMNF | Vancouver Community Withdrawal Management Nurs (Calls WMNFTEXT) | |
| WMNFTEXT | Vancouver Community Withdrawal Management Nursing F (TEXT ONLY) | Subjective: «» Objective: «» Assessment: «» Plan: [Follow up ] with [ ] «» |
| WMS | Withdrawal Management Support | |
| X | VCH-Save Old Version Antenatal Form | |
| XYZ | Pt left voicemail today at | Pt left voicemail today at 1028 re: had MRI recently and now experiencing |
| YCA | Youth Clinic Assessment | |
| YCAIT | Youth Centralized Addiction Intake Team (YCD) | |
| YCAITAS | YCAIT-Alt Schools (calls YCAITASTEXT) | |
| YCAITASTEXT | YCAIT-Alt Schools (TEXT ONLY) | School: «» Indigenous identifying: «» Reason for visit: «» Referral source: «» Needs identified: «» Mental health concerns: «» Outcomes/plan: «» |
| YCAITD | Discharge Note - Youth CAIT (calls YCAITDTEXT) | |
| YCAITDTEXT | Discharge Note - Youth CAIT (TEXT ONLY) | Client discharged from «location» on «date». Discharged to «location». |
| YCCA | Opens YC Counsellor Documentation Form | |
| YCCI | Youth Clinic Counsellor Intake | Reason for referral: «» Reviewed limits of confidentiality: «» Reviewed contact information: «» Electronic health records: «» Reviewed texting and emailing policies: «» Crisis/Emergency resources given: «» Are you currently attached to another service provider/therapist: «» Have you had previous involvement with the mental health system: «» Diagnosis: «» Current/Past medication: «» Prescribed by: «» Disordered eating: «» Substance use: «» Current/Past suicidality: «» Self-harm: «» Current Level of functioning: «» Family/social support: «» Hobbies/activities: «» School/work: «» Peers/significant others: «» Other: «» Outcome/Referral: «» |
| YCDD | Youth Concurrent Disorders Services - Discharge Summary | |
| YCDI | Youth Concurrent Disorders Services - Intake Assessment | |
| YCDT | YCD - Transition Into Independence Program | |
| YDTP | Youth Day Treatment Program (Macro only) | |
| YDTPA | Youth Day Treatment Program - Alumni Group | |
| YDTPG | Youth Day Treatment Program - Group Visit (Macro only) | |
| YDTPI | Youth Day Treatment Program - Youth CAIT Intake(callsYDTPITEXT) | |
| YDTPITEXT | Youth Day Treatment Program - Youth CAIT Intake (TEXT ONLY) | Housing: «» Income Source: «» Education: «» Medical/Developmental History: «» Mental Health: «» Substance Use History: «» Legal History: «» Do you identify Indigenous? If yes, would you like cultural support?: «» Have you or are you involved with MCFD?: «» |
| YDTPSWI | YDTP - Social Work Intake (calls YDTPSWITEXT) | |
| YDTPSWITEXT | Youth Day Treatment Program - Social Work Intake (TEXT ONLY) | Motivation Tell us about why you've chosen to apply to the Day Treatment Program: «» What are the things you want to get out of treatment? «» Housing How does substance use affect your ability to live in your current housing? «» Who do you live with? Do you pay rent? What part of town? «» Is there enough food, clothing, heat, water in your home? «» Family and Social Connection If any, describe the relationship between you and your family. «» Is there a family history of mental illness or substance usage? «» Who have been the supportive people in your life? «» Children Do you have children? «» Child 1 Name: «» | Child Age: «» | Child's Current Living Situation: «» Child 2 Name: «» | Child Age: «» | Child's Current Living Situation: «» Child 3 Name: «» | Child Age: «» | Child's Current Living Situation: «» Child 4 Name: «» | Child Age: «» | Child's Current Living Situation: «» Is there MCFD involvement? «» Spiritual and Personal Development Tell me about your connection to culture and/or spirituality. «» Personal Interests How would you describe your social interactions/lifestyle? «» Tell me about your interests and passions. «» Mental Health How does mental health affect your substance use (or vice versa)? «» What is helpful for you when you're struggling with your mental health? «» How is your sleep? «» Substance Use History Notes on substance use history: «» Effects of peer pressure on substance use: «» Do you use harm reduction supplies/resources? Would you like access to a narcan kit? «» How can we best work with you to help reach your treatment goals? «» History: Alcohol use in past 30 days: «» | Previous: «» Marijuana use in past 30 days: «» | Previous: «» Cocaine use in past 30 days: «» | Previous: «» Crack Cocaine use in past 30 days: «» | Previous: «» Fentanyl/Heroin use in past 30 days: «» | Previous: «» Prescriptions use in past 30 days: «» | Previous: «» Benzodiazepines use in past 30 days: «» | Previous: «» Hallucinogenics use in past 30 days: «» | Previous: «» GHB use in past 30 days: «» | Previous: «» Ketamine use in past 30 days: «» | Previous: «» Ecstasy use in past 30 days: «» | Previous: «» Crystal Meth use in past 30 days: «» | Previous: «» Others: «» use in past 30 days: «» | Previous: «» Life Skills «» Is there any ID that you need? «» Rate where you scale yourself on the following: 1-10 (1 = feeling stuck, 10 = fully self-reliant) Motivation and taking responsibility: «Rate» | «Notes» Practical life skills: «Rate» | «Notes» Money management: «Rate» | «Notes» People and support: «Rate» | «Notes» Substance use: «Rate» | «Notes» Physical wellness: «Rate» | «Notes» Emotional and mental health: «Rate» | «Notes» Education: «Rate» | «Notes» Housing: «Rate» | «Notes» Goal Setting See Clinical CarePlan for Goals and Action Steps. |
| YDTPWIP | YDTP - Weekly Intention Plan (calls YDTPWIPTEXT) | |
| YDTPWIPTEXT | YDTP - Weekly Intention Plan (TEXT ONLY) | Number of weeks in the program: «» Identify a substance use intention for the week Substance Use Goal 1: «» Steps I'll take to achieve this goal: «» Substance Use Goal 2: «» Steps I'll take to achieve this goal: «» Substance Use Goal 3: «» Steps I'll take to achieve this goal: «» What barriers/triggers may arise? Trigger 1: «» How will I overcome this? «» Trigger 2: «» How will I overcome this? «» Finding balance List things that you can do to keep yourself feeling your best this week (e.g., listening to music, reaching out to supports, eating well) «» Appointments or personal goals you'd like to complete this week (e.g., getting ID, seeing doctor, taking meds, etc) 1. «» 2. «» 3. «» |
| YHSP | Youth Shift/Home Stabilization Program (Macro only) | |
| YHSPI | Youth Shift/Home Stabilization Program - Intake(callsYHSPITEXT) | |
| YHSPITEXT | Youth Shift/home Stabilization Program - Intake (TEXT ONLY) | Substance Use History How long have you been using substances? «» What are your goals related to your substance use? «» Reduce? Abstain? Which substances and how much? «» Do youth and caregiver support agree about goals? «» Have you detoxed/withdrawn from these substances before? «» How many times in the past 3 months have you attended detox/withdrawal services? «» What help were you looking for there? «» Did you find it helpful? «» Have you ever attended a group, treatment centre, support recovery, NA, etc.? «» How have substances benefited you? «» What is driving you to want to make a change now? «» What do you see as your strengths in relation to managing substance use change? «» Any history of or interest in OAT? «» Have you experienced an overdose before? «» Discuss risk factors and prevention strategies. «» Housing What is your current housing situation? «» Who lives with you? «» Do you have your own room? «» Do you feel safe where you are living right now? «» Have you been experiencing or witnessing abuse in the home? «» Social Who are your support people? «» When were you last in touch with them? «» Can we talk with them about your substance use and plans? «» Are there additional support people you’re hoping to be connected with or would like to reconnect with? «» What does your average day look like? «» Are you currently working, going to school, etc? «» Who do you consider to be involve in your family? «» What is your relationship like with your family members? «» MH Do you have any mental health history or concerns? «» Have you ever been hospitalized due to mental health? «» Do you feel your mental health is under control? «» Do you have any concerns about how your mental health will be impacted by changing your substance use? «» Have you been experiencing any psychosis symptoms? «» Physical Health Do you have any physical health concerns which you think may impact or be impacted by your withdrawal? «» Do you have a family doctor? «» Do you have health issues you would like to have addressed? «» Have you been hospitalized, had any inpatient stays or ER visits in the past 3 months? «» Legal/Social Issues Have you ever been convicted of a criminal offence? «» Do you have any major social issues which you think my impact your withdrawal? (eg: someone stalking you, a current battle over child custody, etc) «» Goals What are your short term goals for your substance use (in the next week or two)? «» What are your long term goals for your substance use (over the next several months or year)? «» What kind of help are you hoping for from the Youth Home Withdrawal Team? «Y/N» What to expect from withdrawal «Y/N» How to manage withdrawal symptoms «Y/N» Opiate Agonist Therapy «Y/N» Family mediation «Y/N» How to manage cravings «Y/N» Relapse prevention «Y/N» Goal Setting «Y/N» Overdose education «Y/N» Harm reduction supplies «Y/N» Referrals to treatment «Y/N» Connection with long term substance use or concurrent counsellors «Y/N» Cultural support «Y/N» Connection to support groups (for youth or adult) |
| YHSPS | YHSP - Youth CAIT Screening (calls YHSPSTEXT) | |
| YHSPSTEXT | YHSP - Youth CAIT Screening (TEXT ONLY) | Preferred name: «» Contact Information (phone): «» Contact Information (email): «» Updated the above information in the Client Registration Form: «Y/N» Are you housed?: «» What substances are you using?: «» What is the frequency of the substances you are using: «» What impact is your substance use having in your life (e.g. school/work, relationship, physical and mental health, financial)? This helps determine what type of support you require «» Any physical health concerns?: «» Any mental health concerns or diagnoses?: «» Do you have a primary care practitioner/GP/NP? «» Suicidal ideation present?: «» History of seizures?: «» Chance of pregnancy?: «» Medications?: «» Seeking abstinence approach?: «» If seeking abstinence approach, assess if safe to do so in community: «» Seeking harm-reduction approach?: «» Are you currently supported by any professionals or teams in the community?: «» Do you identify Indigenous? Do you identify as Status, Non Status, Inuit, Metis, or Unknown?: «» Have you or are you involved with MCFD?: «» Support Identified by CAIT Clinician: Brief Intervention (2 - 3 sessions): Y/N «» Comprehensive Intake Required: Y/N «» |
| YICMT | Youth Intensive Case Management Team (Macro only) | |
| YICMTAHI | YICMT - Allied Health Intake (calls YICMTAHITEXT) | |
| YICMTAHITEXT | YICMT - Allied Health Intake(TEXT ONLY) | Presenting Issue «» Supportive Relationships Who do you currently consider supportive relationships in your life? «» Who have been the supportive people in your life in the past? «» What do you find supportive in relationships? What makes the above people mentioned supportive? «» What could improve your current relationships? (i.e., better communication skills, spending more time together) «» What are your current strengths within relationships? What are past strengths or resources? «» What are your goals around your relationships? What would you like to work on in this area of your life? «» Plan: See Clinical CarePlan for Goals and Action Steps. Mental Health Have you ever received a mental health diagnosis? Where did this come from? «» Do you have any mental health concerns right now? (i.e., mood, stress/anxiety, attention difficulties, grief, psychosis) «» Have you ever received support for your mental health concerns? (i.e., counselling, inpatient facility, medications) «» What is helpful for you when you're struggling with your mental health? Not helpful? (i.e., strategies used, people you talk to) «» What are your current strengths with your mental wellness? What are past strengths or resources? «» What changes in your mental health are you hoping to see? What would you like to work on in this area of your life? Plan: See Clinical CarePlan for Goals and Action Steps. Wellness and Health Do you have any physical health concerns? «» Have you accessed any primary care services recently? (i.e., hospital, walk-in clinic, nurse practitioner) «» What do you do to keep yourself healthy? What are your current strengths in this area? What are past strengths or resources? «» Is there anything about your health and wellness that is concerning to you at the moment? What are your goals with your physical health and wellness? «» Plan: See Clinical CarePlan for Goals and Action Steps. Housing What is your current housing situation? Has maintaining stable housing been an issue for you in the past? «» Where do you go if you have nowhere to stay? «» What are your current strengths in this area? What are past strengths or resources? «» What is your ideal housing situation? What are your goals around your housing that you would like to work on? «» Plan: See Clinical CarePlan for Goals and Action Steps. Legal Involvement Do you have any current involvement with the Legal System? (i.e., outstanding charges, court dates, probation) «» If so, what support do you need in this area? What are your goals? Plan: See Clinical CarePlan for Goals and Action Steps. Income How are you currently supporting yourself financially? Are you on IA/PWD/Subsidies? «» In the past, how have you supported yourself financially? «» What are your current strengths with your finances? What are past strengths or resources? «» What are your goals around your finances? What do you need to achieve these goals? «» Plan: See Clinical CarePlan for Goals and Action Steps. Life Skills Do you need support in any of the following areas? Personal hygiene: «Yes/Sometimes/No» Making appointments/Getting to appointments: «Yes/Sometimes/No» Meal planning/Cooking: «Yes/Sometimes/No» Budgeting: «Yes/Sometimes/No» At home skills (cleaning, laundry): «Yes/Sometimes/No» What are your current strengths with life skills? What are past strengths or resources? «» What are your goals with life skills? What areas would you like to improve in? «» Plan: See Clinical CarePlan for Goals and Action Steps. Education/Employment What education/employment have you experienced in the past? «» Are you currently working or involved in any training or education? Would you like to be? «» What are your current strengths in employment or education? What are past strengths or resources? «» What are your goals around education and employment? What do you feel would help you success in your goals? «» Plan: See Clinical CarePlan for Goals and Action Steps. Leisure/Recreation Do you have any interests or hobbies (past or present)? What activities are you currently involved in? «» What are your current strengths in this area? What are past strengths or resources? «» What are your goals in terms of interests and hobbies? What would you like to work on in this area of your life? Plan: See Clinical CarePlan for Goals and Action Steps. Cultural/Spiritual Traditions Are there traditions, cultural or spiritual practices you find helpful? Any you practice in your life? «» Are there traditions, cultural or spiritual practices you would like to learn about? Would you like to connect to our Indigenous cultural worker for assistance in any of the following? «Y/N» Elder Support and Knowledge Keepers for counsel and reflection «Y/N» Access and support for local Indigenous Ceremony «Y/N» Accessing cultural implements and ceremonial smudge for wellness and hard reduction «Y/N» Access to Culturally Sensitive Medical Services through Kilala Lelum «Y/N» Support and Indigenous Advocacy for accessing primary health and social services «Y/N» Screening and application for Secure Certificate of Indian Status «Y/N» Screening and application for First Nations Health Benefits «Y/N» Connecting with local resources for Food Security (i.e., UNYA Food Bank) «Y/N» Connecting with local support and events for Indigenous 2-Spirit, LGBTQ+ (including ceremony) «Y/N» Referrals and connecting to Indigenous Drug and Alcohol Treatment programs «Y/N» 1:1 Outreach Support for general wellness and care «Y/N» Exploring genealogy and specific cultural identity Plan: See Clinical CarePlan for Goals and Action Steps. Safety Plan What are some things that trigger you? «» What usually happens when you are triggered? (i.e., yelling, swearing, using substances, cutting, violent behaviour) «» What helps you when you are feeling triggered? What coping strategies can you use? «» Who are supportive people or places you can go to if you feel triggered? «» Additional comments or important things to know about you? «» Current Professional Supports and Contact Info «Support1»: «Contact Info1» «Support2»: «Contact Info2» «Support3»: «Contact Info3» «Support4»: «Contact Info4» «Support5»: «Contact Info5» |
| YICMTR | Youth ICM Team (YICMT) Rounds | |
| YICPO | Youth Indigenous Cultural Practitioner - Outreach | |
| YITR | Youth ICM Team Referral (calls YITRTEXT) | |
| YITRTEXT | Youth ICM Team Referral (TEXT ONLY) | Reason for referral and current goals: «» Current barriers experienced: «» Current substance use: «» Past substance use: «» Current housing: «» Professionals who work with this client: «» Best way to connect with youth: «» Any additional info: «» |
| YOT | DTES Youth Outreach Team (Macro only) | |
| YOTI | DTES Youth Outreach Team - Intake (calls YOTITEXT) | |
| YOTITEXT | DTES Youth Outreach Team - Intake (TEXT ONLY) | Are you currently homeless or without a stable place to live? «» Ethnicity you identify as: «Y/N» Indigenous «Y/N» Black «Y/N» Asian «Y/N» South Asian «Y/N» Hispanic/Latino «Y/N» Caucasian «Y/N» Other: «» What services are you looking to achieve? «Y/N» Drop in «Y/N» Meals «Y/N» Help with forms (i.e., PWD, Income Assistance) «Y/N» Shower «Y/N» Case Management «Y/N» Clinic/Medical Services «Y/N» Shelter «Y/N» Drug/ETOH «Y/N» Other: «» Do you identify as part of the LGBTQ+ Community? «Yes»«No»«Prefer not to answer» Where you involved in the following experiences? «Y/N» Legal involvement (i.e., Probation) «Y/N» Physical assault «Y/N» Gang violence «Y/N» Prostitution/sexual exploitation Current year in school or highest completed education in school: «Y/N» High school: Grade «» «Y/N» Some college «Y/N» Completed college «Y/N» Other: «» Summary of youth's situation: «» Notes: «» |
| YTIPI | Transition into Independence Program - Intake (calls YTIPITEXT) | |
| YTIPITEXT | Transition into Independence Program - Intake (TEXT ONLY) | Housing Please briefly describe your housing history and current housing situation. Current housing situation: Approximate Dates: «» Type: «Shared, 2br, shelter, street, with parents, etc.» Cost of Your Rent: «» Housing history 1: Approximate Dates: «» Type: «Shared, 2br, shelter, street, with parents, etc.» Cost of Your Rent: «» Reason for Leaving: «» Housing history 2: Approximate Dates: «» Type: «Shared, 2br, shelter, street, with parents, etc.» Cost of Your Rent: «» Reason for Leaving: «» Housing history 3: Approximate Dates: «» Type: «Shared, 2br, shelter, street, with parents, etc.» Cost of Your Rent: «» Reason for Leaving: «» When you think about achieving independence, what does this look like for you? «» Income Please identify your current source of income: «Income Assistance, PWD, Employment, Student Loan, Other» What is your total income (including any shelter portion money)? «» How much of your income is intended for rent? «» Education and Work Experience Please list your last completed level of education: «» Please list any other training you have done: «First Aid, Food Safe, etc.» Please list any work or volunteer experience and dates involved: «» Substance Use Are you currently, or have you in the past struggled with substance use? «» What is/was your drug of choice? «» How often and how much are you using? «» What are your short term goals around substance use? «» What are your long term goals around substance use? «» Are you accessing any supports regarding your substance use? «NA, AA, Drug and Alcohol Counsellor» If so, please list and explain these supports: «» Health Do you have any physical health issues, medical conditions, or concerns we should know about? If so, please describe. «» Do you have any mental health diagnoses or mental health challenges or concerns? «Depressed mood, Anxiety, Attention difficulties/hyperactivity, Brain injury» When you feel like your mental health is not great, what has worked for you to improve it? «» Medication is one way of possibly helping you. Are you open to the idea in combination with other holistic methods? «» Support Which supports do you feel that you are in need of? «Housing search, Mental health, Grocery shopping, Budgeting, etc.» Who provides you with support? «Family, Friends, Counsellor, Other professional supports» Goals What goals would you like to complete by the end of the 18 months in TIP? «Reduce substance use, Budgeting, Meal planning, Healthy hobbies/activities, Obtaining employment» Plan: See Clinical CarePlan for Goals and Action Steps About You Do you have any hobbies you like to do? «» Do you practice any self-care or want to learn about self-care? «Share what, if any, practices you do» Please list three personal strengths/characteristics about yourself: «» Emergency Contact Information Name: «» Relationship: «» Phone Number: «» |
| Z | Signature with Clinician college ID | «Letter.LoggedOnUser.Title»«Letter.LoggedOnUser.FullName» College ID «Letter.Patient.Macro.COLLEGEID» on «Letter.Letter.Today» at «Letter.Letter.CurrentTime» |
| FALSE | Consitent with false positive | Consistent with false positive |