User Tools

Site Tools


Sidebar

emergency

Emergency Clinic

Most of this information comes form the green sheet in most of the emergency bays.

  1. Log in to Axium
  2. Open Rolodex and open your patient's EHR (make sure you have access to their chart before you go get them - if not, they can fix it out front)
  3. Go get your patient
  4. Hand them the copy of the Emergency Limited Consent in the cubicle for them to look over
  5. Go to Attachments and open a “Emergency Limited Consent” form (under “Consent Forms” – new record button – ”…” button)
  6. Have them sign that they consent on your tablet (just close the form that comes up and it'll let the pt sign)
  7. Open up these forms:
    1. Health History (HHFGN)
    2. Emergency Limited Evaluation (EEXER)
    3. Orders and Exposure Record (OERXER)
    4. Oral Surgery Consultation (CONOS)
  8. Add the Limited Oral Evaluation code (D0140)
  9. Fill out the HHx form (just med, not dent)
  10. Fill out the Emergency form to the stopping point (see Chief Complaint) and check in with faculty
  11. Do your basic extraoral and intraoral exams and note your Clinical Findings
  12. Decide on what radiographs you'd like to take
    1. Fill out the Orders and Exposure Record form
    2. Add the appropriate codes
      1. D0220 = 1st PA/BW ($8)
      2. D0230 = Add'l PA/BW ($6)
      3. D0330 = Pan ($50) (can include up to 7 PA's)
  13. Go to the faculty and present your clinical findings and which radiographs you'd like
  14. Take the radiographs and interpret your results (add to the form)
  15. Formulate a Diagnosis, and finish Emergency Limited Evaluation Form including the Options and Proposed Emergency Treatment
  16. If the patient is in need of an extraction (most likely), fill out an Oral Surgery Consult - Focused Patient Assessment and add the consult code to the chart (D7010)
  17. Present diagnosis to faculty, and have OS consult approved
  18. Move the D0140 and Radio codes to Completed

Oral Surgery Consult

Assuming you're doing an OS consult, here's the procedure for that:

  1. Go to the OS department and walk all the way to the back where there are a few computers in a small room
  2. Find a faculty in there and let them know you're coming form an emergency for a consult
  3. Tell them your chart number, and give them an overview of your case - including if you think it'll be a surgical vs simple extraction
  4. They'll determine the urgency of the case and give it a category, as well as enter the codes for the extraction
  5. On your way out, stop at the front desk in OS and let them know you have a patient from Emergency that needs an extraction, and what the faculty determined for the category and who would the case would be assigned to (DS3/4/Resident)
    1. If it's a category 2 and they're full, or if it's a category 3 case, they'll tell you times that they have open in the next day or two
  6. Go back to Emergency and get your patient - take them out to the “caves” in the lobby to sign their treatment plan
  7. Walk your patient back to the OS clinic and schedule their appointment
  8. Take your patient to the lobby to see the financial people and to check out

Progress Note

0140, 0220, 7010, etc…

EMERGENCY VISIT

Reviewed HHx (Indicate any existing conditions/positive health findings i.e.: allergies, HTN, Diabetes, Infectious diseases, Medications) or Patient denies history of asthma, allergies, CVD, DM, ID, seizure disorders, psychiatric disorders, surgeries, hospitalizations, medications.

BP _/_ mmHg LASit/RASit P ___ bpm S&R

Radiographs: 1 PA/PAN/BW

Tooth #xx Dx:

Discussed with patient all treatment options, patient choose extraction treatment. Patient referred to O.S. for extraction.

O.S. appointment: date and time

Rx: none/prescription

Patient was advised about the need and importance of comprehensive dental care.

emergency.txt · Last modified: 2013/06/21 21:15 by brent