SOAP Notes & Attestation

SOAP Notes & Attestation

Tele-Notes
telehp

*** w/ PMhx sig for ***. Come in complaining of ***; patient was last seen normal at ***

No recent nausea, vomiting, fever, chills, cough, Flu-like symptoms. No recent Major Fall or trauma

TeleTIA

#TIA workup for Etiology

  • Routine CTA Head and neck
  • Routine MRI Brian without Contrast
  • Transthoracic echocardiogram (TTE)
  • CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG #Secondary Stroke Prevention
  • ASA 81 now and Daily
  • ASA 325 now and Daily
  • Plavix 75 now and Daily
  • High Dose Statin (Lipitor 80) #General Medical recommendations
  • Liberalize SBP to less than 220 for 24 hours
  • Decrease BP goal by 15% daily after first 24 hours
  • Start DVT prophylaxis (preferably via LMWH heparin)
  • Order therapies as indicated (Physical, occupational &/or Speech) #Continuity of Care
  • Inpatient and outpatient Neurology f/u #P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider
TeleStroke

#Acute Stroke Intervention

  • Not a tPA candidate outside time window
  • Not a tPA candidate mild disabling Stroke symtoms
  • Not a tPA candidate NIHSS now Zero
  • Not a tPA candidate on Direct thrombin inhibitors
  • Not a tPA candidate on Coumadin
  • Not a thrombectomy candidate NIHSS < 6 #Stroke workup for Etiology
  • Routine/STAT CTA Head and neck
  • STAT CTPerfusion (if Available)
  • Routine MRI Brian without Contrast
  • Transthoracic echocardiogram (TTE)
  • CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG #Secondary Stroke Prevention
  • ASA 81 now and Daily
  • ASA 325 now and Daily
  • Plavix 75 now and Daily
  • High Dose Statin (Lipitor 80) #General Medical recommendations
  • Liberalize SBP to less than 220 for 24 hours
  • Decrease BP goal by 15% daily after first 24 hours
  • Start DVT prophylaxis (preferably via LMWH heparin)
  • Order therapies as indicated (Physical, occupational &/or Speech) #Continuity of Care
  • Inpatient and outpatient Neurology f/u #P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider
TeleTPA

#Acute Stroke Intervention

  • tPA candidate
  • SBP Goal less than 180
  • tPA infusion and bolus per patient weight
  • Post tPA precautions and monitoring
  • STAT CTA Head and neck rule out Large vessel occlusion
  • STAT CTP to rule out mismatch (if available) #Stroke workup
  • Routine MRI Brian without Contrast
  • Transthoracic echocardiogram (TTE)
  • CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG #Secondary Stroke Prevention
  • High Dose Statin (Lipitor 80)
  • Antithrombotics post 24 hours of tPA per local neurologist #Continuity of Care
  • Inpatient and outpatient Neurology f/u #P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider
TeleClot

#Acute Stroke Intervention

  • tPA candidate
  • SBP Goal less than 180
  • tPA infusion and bolus per patient weight
  • Post tPA precautions and monitoring
  • Thrombectomy Candidate NIHSS *** and mRS ***
  • Transfer to Thrombectomy center via flight for life #Stroke workup
  • Routine MRI Brian without Contrast
  • Transthoracic echocardiogram (TTE)
  • CBC, BMP, Coags, HbA1C, LDL, Telemetry, EKG #Secondary Stroke Prevention
  • High Dose Statin (Lipitor 80)
  • Antithrombotics post 24 hours of tPA per local neurologist #Continuity of Care
  • Inpatient and outpatient Neurology f/u #P.S. Findings, Assessment/plan, recommendation and future care discussed with primary local provider and receiving physician at thrombectomy capable center
TeleRe

#Recrudescence of an Old stroke

  • Infectious and metabolic workup per ED physician
TeleMRA
  • Routine/STAT MRAngio Brain without contrast
  • Routine Bilateral Carotid Ultrasound
TeleATT
ITH Teleneurology is a consultative service supporting the local providers for this patient. Relevant patient information, acquired through discussion with emergency providers, independent assessment, and review of the local EMR, is to be shared with the teleneurologist at the time of consultation request. The Acute Teleneurology team should be contacted with any neurologic worsening or clinical changes, new test results, or new patient history that is reported to or discovered by the local team following completion of the teleneurology consultation, specifically that which has the potential to impact the consultative recommendations
Billing
Critical care time

This patient is critically ill due to acute impairment of the multiple system as a result of *** with high probability of imminent or life threatening deterioration in the patient’s condition that requires ICU management.

The care that I provided includes detailed clinical assessment, interpretation of multiple physiological parameters, high complexity decision making to assess, manipulate, and support vital system function to treat multi system failure and to prevent further life threatening deterioration of the patient's condition.

I provided *** minutes of Critical Care to this patient. This included review of recent events, clinical examination and review of data on multiple occasions, management of multiple organ systems, and discussion about treatment with the members of the multidisciplinary ICU team and documentation. This time does not include time spent in performing any separately billed procedures.

@JSKME@

Providing Physician Attestation

I reviewed events, examined the patient and discussed management and plan with ICU team. Agree with examination findings and assessment and plan as noted above by {jskapp:156787} with following opinions of my own.

Briefly, @NAME@ is a @AGE@ @SEX@ with ***

Exam:

@TMAX(24)@

@LASTBP(2)@

{conscience:123102}, Oriented x {NUMBERS 0-4:108966},

PERRLA, EOMI, Dysarthria {Dysarthria:155248},

LUE {NEURO RATING SCALE 5:119244} RUE {NEURO RATING SCALE 5:119244}

LLE {NEURO RATING SCALE 5:119244} RLE {NEURO RATING SCALE 5:119244}

Assessment and Plan:

I collaborated with formation of above stated plan and agree with documentation.

Salient Plan for today: ***

This patient is critically ill due to acute impairment of the multiple system as a result of *** with high probability of imminent or life threatening deterioration in the patient’s condition that requires ICU management.

The care that I provided includes detailed clinical assessment, interpretation of multiple physiological parameters, high complexity decision making to assess, manipulate, and support vital system function to treat multi system failure and to prevent further life threatening deterioration of the patient's condition.

I provided *** minutes of Critical Care to this patient. This included review of recent events, clinical examination and review of data on multiple occasions, management of multiple organ systems, and discussion about treatment with the members of the multidisciplinary ICU team and documentation. This time does not include time spent in performing any separately billed procedures.

@JSKME@

E&M Billing Service

Providing Physician Attestation

I reviewed events, examined the patient and discussed management and plan with ICU team. Agree with examination findings and assessment and plan as noted above by {jskapp:156787} with following opinions of my own.

Briefly, @NAME@ is a @AGE@ @SEX@ with ***

Brief Exam:

@TMAX(24)@

@LASTBP(2)@

{conscience:123102}, Oriented x {NUMBERS 0-4:108966},

PERRLA, EOMI, Dysarthria {Dysarthria:155248},

LUE {NEURO RATING SCALE 5:119244} RUE {NEURO RATING SCALE 5:119244}

LLE {NEURO RATING SCALE 5:119244} RLE {NEURO RATING SCALE 5:119244}

Assessment and Plan:

I collaborated with formation of above stated plan and agreed with documentation.

Salient Plan for today: ***

Counseling: Discussed diagnosis and prognosis with {PATIENT/OTHERS:137602}.

Coordinating: Reviewed plan of the day with nurse, nurse practitioner, pharmacist, PT/OT/Speech services, Social worker, charge nurse and ***.

I provided {jsktime:155882} of patient care at bedside. This included review of recent events, clinical examination and review of data on multiple occasions, management of multiple organ systems, and discussion about treatment with the members of the multidisciplinary team and documentation. More than 50% of time was spent in counseling and coordinating care of the patient. This time does not include time spent in performing any separately billed procedures.

@JSKME@

Providing Physician Attestation

I reviewed events, examined the patient and discussed management and plan with ICU team. Agree with examination findings and assessment and plan as noted above by {jskapp:156787} with following opinions of my own.

Briefly, @NAME@ is a @AGE@ @SEX@ with ***

Brief Exam:

@TMAX(24)@

@LASTBP(2)@

{conscience:123102}, Oriented x {NUMBERS 0-4:108966},

PERRLA, EOMI, Dysarthria {Dysarthria:155248},

LUE {NEURO RATING SCALE 5:119244} RUE {NEURO RATING SCALE 5:119244}

LLE {NEURO RATING SCALE 5:119244} RLE {NEURO RATING SCALE 5:119244}

Assessment and Plan:

I collaborated with formation of above stated plan and agreed with documentation.

Salient Plan for today: ***

Counseling: Discussed diagnosis and prognosis with {PATIENT/OTHERS:137602}.

Coordinating: Reviewed plan of the day with nurse, nurse practitioner, pharmacist, PT/OT/Speech services, Social worker, charge nurse and ***.

I provided {jsktime:155882} of patient care at bedside. This included review of recent events, clinical examination and review of data on multiple occasions, management of multiple organ systems, and discussion about treatment with the members of the multidisciplinary team and documentation. More than 50% of time was spent in counseling and coordinating care of the patient. This time does not include time spent in performing any separately billed procedures.

@JSKME@

Attestation
I, *** personally examined the patient, reviewed the history and examination with the nurse practitioner Emmy Kirui and together we formulated the above plan.

NIHSS
AIS A&P Note
ICH A&P Note
MLP Initial
Other Epic Notes
Stroke Team/Critical Care H&P
Stroke Outpatient Note
JSK - TCD
JSK - SAH
JSK - ROS
JSK - NCC Note
JSK - ME
JSK - LP Procedure Note
JSK - Epilepsy
JSK - Brain death
JFSAP
Digital Voice Disclosure