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.mscChestPain


.mscChestPainOrderSet
Chest pain:
- trend trops
- VS per routine
- telemetry
- up as tolerated
- cardiac diet
- daily wt, I/O
- pulse ox, continuous
- tobacco cessation
- PTOT eval and treat
- AM BMP, CBC
- Tylenol
- magnesium hydroxide
- Zofran
- asa
- lovenox


.mscChestPainMedicalNecessity
- "CP" is a manifestation of an underlying condition, Angina and CP aren't interchangeable
- CP 2/2 CAD with angina
- CP 2/2 Pleurisy
- CP 2/2 Costochondritis
- CP 2/2 Cardiac Dysrhythmias
- CP 2/2 Lung mass
- CP 2/2 ACS
- CP 2/2 gerd/gastritis
- CP 2/2 biliary colic,
- CP 2/2 Pericarditis
- CP 2/2 musculoskelatal
- CP 2/2 anxiety
- CP 2/2 uncontrolled HTN

Observation Criteria
- CP relieved prior to admission orderes
- VSS
- EKG benign or no sig changes from prior
- CXR benign
- CEA NL

IP Criteria
- STEMI, NSTEMI, ACS w/ BBB (new or undetermined age), sig EKG changes, Unstable Angina
- Unstable Angina - characterized by increasing severity, duration, frequency or intensity.
- ACS is Unstable Angina for coding purposes.
- NSTEMI - clarify the significance of the elevated CEA level
- Use PE, EKG, CEA to elect 1 of: Non-cardiac dx, Chronic stable angina, possbile ACS, ACS

- AHA - 30-day negative predictive value > 99% for ACS reported when:
- TIMI risk = 0
- NL EKG
- NL CEA at 0 and 2 hours.



2 midnights happen change to IP.
- low risk / interment chest pain with stress in the AM - make them observation.
- CP, NSTEMI are all IP
- Low risk for chest pain - document why needs IP
— not safe for OP care
— failed OP care
— persistent chest pain symptoms
— slide 16: 
“patient needs inpatient status to manage risk”
Pertinent risk factors include: - add these, copy to smart phrase
Medium to high risk, symptoms, the following risk factors:
Family History (fa/br < 55; mo/si < 65) Gender Age (m > 45, w > 55)
Stress Level High Blood Pressure High Cholesterol
Diabetic/Pre-diabetic Obesity Smoking
Lack of physical activity Unhealthy diet
Given the patient’s history and risk factors, there is no absolute
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How to detect cigarette smoking: https://en.wikipedia.org/wiki/Cotinine 
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Family Practice CPT tricks https://mail.google.com/mail/u/0/#inbox/158f8d6d02e7455d
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- why cefadroxil ?
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CDS Supervisor: Terri Haggard 632-9801
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Ohio Narcotic Subscribing Guidelines: http://ohiorxguidelines.com/thank-you/
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Read this: Theophylline in Cheyne Stokes Breathing: ref
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Always be sure and asa and a statin are started on heart patients.
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Hospice Cancer Nausea suggested treatment regimen:
- Decadron 4 mg, Benadryl 25 mg, Reglan 10 mg IVP q 6 hr ATC for nausea
- Margaret Booker, RN CHPN 792-6900
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Long QT - things we can do:
- D/C Zofran and start phenergan for nausea in the setting of prolonged QTc.
- ciprofloxacin and flagyl also increase QT
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Plavix interactions 
- protonix causes more Plavix interactions than omeprazole, although protonix is generic and cheaper
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Protonix increases likelihood of CDIFF 
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"Acute on Chronic Renal Failure
 - IP consult to Nephrology - thank you"

- per clinical documentation becomes:

"Chronic kidney disease stage 3 in the setting of acute on chronic renal failure with BUN/Cr/GFR 34/1.6/32, monitor, nephrology consult."
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atorvastatin reduced to 40 mg (no benefit to high dose statins in patients older than 75)
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Surgical Risk Factor Calculator: http://riskcalculator.facs.org
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- Prophylactic heparin is usu 5000 U TID SC. If person is in their 80s, then 5000 U BID.
- Heparin t1/2 is 2 hrs
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.mscCHFX - this is from the MAH Heart failure card.
Admitting a CHF Patient:
- use CHF order set
- consult CHF Nurse
- Update problem list to reflect HF Diagnosis
- Document NYHA class
- Enter LV Function (can be PTA, during hospitalization or after discharge).
Discharging a HF Patient
- Order HF follow up appointment within 7 days
- Order echo (for LV function) if not already done.
- Document NYHA class
- if EF < 40% - order the following:
1. ACEI/ARB/ARNi - if not prescribed, document contradictions: allergy, moderate to severe AS,
    angiodema, hyperkalemia, hypotension, renal artery stenosis, worsening renal function or renal ds
    or dysfunction.
2. Evidence based beta blocker (carvedilol, metoprolol CR/XL, bisoprolol) - if not prescribed, document 
    contraindications (allergy, 2nd or 3rd degree heart block w/o pacemaker, COPD, severe hypotension,
    etc.
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DM2 diabetes mellitus II - must be on ACEI and Aspirin per American Diabetes Association guidelines. 
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Paracentesis - always order cell count, gram stain an cultures in patient with ascites 520750
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Hyperlipidemia - No evidence of Rhabdomyolysis or other adverse effects, cont statin.
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Cardiac Stress - order exercise stress test for exercise only.
- add Myoview for nuclear imaging after the walking test.
- use Lexiscan if you don't want to the pt to walk - it contains the dipyramidol stimulant.
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- Acute MI is acute only for 4 weeks
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.mscAbdPain
- Frequently the result of IBD, 75% of healthy adolescent students endorse it.
- RUQ / RLQ / LUQ / LLQ
- +/- nausea, +/- emesis
- probable underlying cause
- ex: 79 yo M adm w/ mid-epigastric abd pain, w/o nx or vm, guaiac + stool, EGD: esophagitis, g. ulcer
- code ex1: fvr, nx, vm, RLQ pain; code ex2: esophagitis, gastic ulcer
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.mscACS
NSTEMI / STEMI (anterior wall, LAD) - [evolved from NSTEMI]

- subsequent NSTEMI / STEMI & vessel (only if < 4 weeks, state date of prior MI) Code: “subsequent stemi” and “stemi LAD” or whatever site

- differentiate between cp/angina and true MI

- thrombolytic therapy (given / not given)

- all possible codes in module: subsequent STEMI, STEMI LAD, NSTEMI, STEMI right coronary artery (RCA not recognized)

- stat 1.5 million / year, 500K deaths outside hospital.

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.mscAms
Acute / Chronic Encephalopathy (not AMS)
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.mscAnemia
Acute / Chronic / Acute on Chronic / Blood Loss Anemia
- cause: blood loss, chronic renal ds, malignant neoplasm
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.mscARF - sort this out

ARF w/in 48 hrs / absolute incr in SCr / % incr in SCr / reduction in UO (staging in attachments)
- 2/2: ATN, obstruction, severe dehydration

ARF (same as AKI) 2/2 ATN, acute cortical necrosis, acute medullary necrosis, other. (ARF/AKI are not same as Acute Renal Insuff or AKD)

- defined as: increased cr by >= 0.3 mg/dl w/in 48 hrs

                     increased cr by >= 1.5 baseline over past 7 days

                     UOP <0.5 ml/kg/hr for 6 hrs


.mscRenalFailure

Acute (renal insufficiency / AKI) / on / Chronic Renal Failure Stage ***
- 2/2: rhabdomyolysis, drug toxicity, glomerulonephritis
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.mscCellulitis
- 90% increase in adm for cellulitis since 1997
- Location, Laterality, Organism, underlying (trauma, foreign body)
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.mscCHF

Acute / Chronic / Acute on Chronic, Systolic / Diastolic / S&D HF  (acuity, type of HF, assoc condition)

- type: systolic (EF<40) or diastolic (on echo) or both

- associated w/ myopathy (hypertensive, alcoholic, sarcoid) cardiac surgery, other surgery, valvular ds, r hear ds

- complications: arrhythmia, acute respiratory failure, acute pulmonary edema

- comorbidities: CAD, DM, etc.

Ex: 60 yo M w/ Acute on Chronic Diastolic HF, associated w/ Afib, chronic, on Coumadin


Where diuretics act in the kidneys: (Dr. Lancaster)

Diuril - PCT

Torsemide - middle conv tubule

Lasix - middle conv tubule

Xaroxalin - DCT


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.mscCKD

CKD Stage 1 > 90, 2 60-90, 3 30-59, 4 15-29, 5 < 15, ESRD on HD (If both CKD and ESRD are documented, ESRD is assigned)

- 2/2: DM, HTN, HD dep / not dependent

- if 2/2 DM code DM first then CKD, same for HTN.

- EX. 55 yo w/ ESRD 2/2 DM2 adm w/ hyperkalemia require acute HD: code DM2, ESRD, Hyperkalemia, HD dep [Z99.2]

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.mscCOPD
- 3rd leading cause of death in the US. Prev: 13-24 million, cost: 50B
- COPDAE, acute, chronic, both, bronchitis, PNA, organism, +/- tobacco, w/ MCC of acute respiratory failure ref
- ex: COPD AE w/ tob abuse, 2/2 LLL PNA, +methacillin sen staph
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.mscCOPDAsthmaPNA
COPD / Asthma / PNA w / Acute / Chronic / Acute on Chronic Respiratory Failure 
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.mscDM
Diabetes Mellitus
- type 2
- controlled / uncontrolled
- complications:
- comorbidities:
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.mscFunctionalQuadriplegia
- Functional Quadriplegia 2/2 dementia / Alzheimer's Ds / ALS / MS / Huntington's Ds / Parkinson's Ds / RA / Debilitating Contractures 
- use the phrase "total assist" or "maximum assist" in addition to FQ
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.mscGIB
- LGI MCC: diverticulosis - 50%, ischemic colitis, anorectal lesions
- UGI - 20,000 deaths annually
- gastric, esophageal, upper, lower, rectal, hemorrhoidal, post-op / acute, chronic, recurrent
- cx: diverticulosis, ulcers, angiodysplasia, PUD
- meds: NSAIDS, warfarin
- contributing factors: tobacco, etoh, substance abuse, radiation, other
- subsequent dx: anemia 2/2 blood loss
- include: acute blood loss anemia, chronic anemia and/or GIB and chronic GIB
- blood in stool  or melana (guaic + is a lab result, not a medical problem)
- ex: 58 yo M w/ etoh dep adm for NSAID-induced gastric ulcer w/ acute upper GIB & ABLA  
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.mscHHD
Hypertensive Heart Disease = HTN + AKI + CHF
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.mscMalnutrition
Malnutrition
- type: protein calorie malnutrition
- severity: mild, moderate, severe
- BMI: ?
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.mscOpioid
- Opioid dependence with liver damage / impaired cog fn / depression / risk of withdrawal
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.mscPancreatitis
Acute Pancreatitis w/o infection 2/2 gallstones / ETOH induced / drug induced / biliary stone / idiopathic
- treated w/ NPO, IVF, pain management, lipase monitoring, and other treatments as ordered
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.mscPNA
(HCAP/GNR) / (CAPNA), +/- POA, 2/2: aspiration / G+/ MRSA / Pseudomonal / vent assoc / chemical / viral / assoc w/ HIV-AIDs
- laterality: L / R / BL
- location: UL / ML / LL
- w/ w/o signs of sepsis
- w/ w/o respiratory failure
- core measures: blood cx, abx, abx taken during past 24 hr ?
- Note: - Use GNR instead of HCAP - HCAP/GNR gets us 2 more days.
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.mscCellulitisUTI
Cellulitis / UTI / +/- Sepsis / 2/2 UTI, +/- POA
- probable cause: foley complication / suprapubic catheter (for UTI)
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.mscRespiratoryFailure
Acute / Chronic / Acute on Chronic / with Hypoxia, Hypercapnea or both / Respiratory Failure
- w/ tachypnea (RR>20) or apnea And one of: PaO2<60 or Pulse Ox<90 on RA / PaCO2 > 50
- comorbidities: COPD, Asthma, PNA
- MCC in elderly: CHF
- Outcome more dependent on dysfunction in other vital organs than on severity of respiratory failure.
- sx of ARF: dyspnea, cyanosis, use of accessory mm, inability to speak full sentences
- ex: Acute on Chronic Respiratory Failure with Hypoxia
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.mscSepsis
Sepsis w/ suspected / proven infection + >= 2 of the following (hosp can go with 2 but needs 3)
- fever (T>101.3 or 38.5) or hypothermia (T<95F or T<35C)
- tachypnea (RR>20 or pCO<32)
- tachycardia (HR>90)
- WBC >12000 or <4000; or greater than 10% bands 
- w/ MCC of: (one of the following) ref
severe - mottled skin / cap ref >= 3s / AMS change / UOP < 0.5 ml/hr for at least 1 hr in spite of hydration
severe cont: lactate > upper limits of NL / thrombocytopenia < 100K / DIC / Acute CHF
severe cont: Acute LVR Dysfn w/ bili > 2x UL NL 
severe cont: Acute Lung Injury / ARDS (PaO2/FiO2 < 250)
severe cont: ARF (cr > 2X UL NL)
septic shock - sepsis + hypotension (SBP < 60 or < 80 if prev HTN) unresponsive to 30 ml/kg NS
- POA 2/2 GNR / E.Coli / Serratia / Pseudomonal / MRSA / other underlying localized infection
- active secondary causes (MCC, CCs)
- if septicemia document sepsis and septicemia
- ex: MRSA septicemia / severe sepsis POA / ARF w/ ATN 2/2 severe sepsis / Acute LLL PNA / Vascular dementia w/ depressive features
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Focus on Sepsis Core Measure
Sepsis is responsible for 1 in 12 hospitalizations but 40% for deaths.  For patients who survive to discharge, sepsis is the most common cause of readmissions (10% of all readmission diagnoses).   Two-thirds of these patients are over age 65, which captures the attention of Medicare resulting in sepsis as a core measure.   SIRS (systemic inflammatory response syndrome) is not the same as sepsis in ICD-10, adding SIRS does not code to sepsis. 
Components of the Sepsis Core Measure
All or none bundle includes severe sepsis and septic shock with
- Lactate, initial and repeat within 6 hours (from when severe sepsis identified)
- Blood culture
- Broad spectrum antibiotic
- IV crystalloid volume expansion 30 ml/kg within 3 hours of presentation
- Vasopressor for persistent hypotension in hour following IV fluids (SBP < 90)
- Document cap refill and presence of skin examination (“mottled,” “not mottled”)
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.mscStroke

(Acute) Ischemic (87%) / Hemorrhagic, embolic / thrombotic

- location / laterality (l or r handed) (LMCA, left …)

 tPA - not a candidiate / s/p tPA

- complications: hemiparesis / hemiplegia / (dom / non-dom side) / coma / cerebral edema / hydrocephalus, expressive aphasia

- comorbidities: DM / Afib / Tobacco Abuse
163.311 - thrombotic stroke RMCA

163.412 - embolic stroke LMCA

strokes kill 130,000 Americans / yr (1/20 deaths) and is leading cause of long-term disability

- 87% are ischemic

- cost: 34 billion

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.mscUTI
- Acute cystitis w/o hematuria POA  2/2 GNR / G+ / yeast w/o chronic indwelling catheter
- Acute cystitis w/o hematuria POA  2/2 GNR / G+ / yeast w/o chronic indwelling catheter
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.mscHyperK
Hyperkalemia 
- albuterol 2.5 mg neb x1
- caclcium gluconate 1 g in dextrose 5% 100 ml IVPB 1g IV at 100 ml/hr for 60 minutes, infuse at 1g/hr
- dextrose 50% solution 25 g IV
- insulin regular (HUMULIN; NOVOLN R) inj 10U IV
- sodium polystyrene (IKayexalate) 15 gm/60ml suspension 15g oral, once
- EKG
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.mscVanc
- use vanc x 3 days IV then linezolid x 11 days for 14 total days of treatment for MRSA cellulitis.
- use dalbavancin on days 1 and 8 to achieve the same (DISCOVER 1 and 2 trials)
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Stats:     
             
CHF - 5.1 million w/CHF, 1/9 deaths in 2009, 50% die w/in 5 years of dx, 32B annually
               
ARF - ARF complicates 5% of all admissions and 30% of all ICU admissions.

- 36% of all hospitalizations in HD pts were followed by readmission in 30 or fewer days. (2x that of non-ESRD pts)

- 38% of Medicare expenditures for ESRD are for hospitalization.

- Only 50% of ESRD patients are still alive after start of ESRD therapy.

- Over 65 mortality is 2X that of other sick people.

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Following is a link to the PDFs given by Sound in GDrive - review and integrate after finish w/plastic handouts.

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Remember to use "probable" when able.
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.mscTaper

Steroid Taper:
Take 4 tabs (40mg) daily x 2 days, then 3 tabs (30mg) x 2 days, then 2 tab (20mg) x 2 days, then 1 tab (10mg) x 2 days, then stop. Disp #20.
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.mscGenAdm

General Admission Order Set:
Pain
- acetaminophen (mild)
- tramadol (mod / severe)
- morphine 2mg Q4H PRN (severe)
Bowel Mgt
- Mag OX
VTE
- lovenox
Admitted to: Med/Surg, Tele
- Full Code
- VS per routine
- Up with assistance
- General diet
- Daily weights, I/O
- Tobacco Cessation
- Pulse Ox spot
- PTOT eval and treat
- Saline flushes
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.mscIJ

PROCEDURE: Central venous line placement left internal jugular vein
CONSENT: The procedure, risks, and benefits were explained to patient's daughter and consent was obtained.
TIME OUT:The patient and procedure were properly identified with the nurse in the room.
STERILE PREP: Full maximum sterile field/barrier technique was followed (with cap and mask and sterile gown and sterile gloves and large sterile sheet and hand hygeine and 2% chlorhexidine for cutaneous antisepsis).
LOCAL ANESTHETIC: Aqueous lidocaine 1%
PROCEDURE: 
Using direct ultrasound guidance, a left internal jugular vein central venous catheter was placed using a modified seldinger technique without difficulty. Excellent return of non-pulsatile, dark venous blood from all lumens. All lumens were flushed with normal saline. Minimal bleeding occurred and there was hemostasis prior to conclusion of procedure. Catheter was sutured in place and a sterile dressing with biopatch was placed.
COMPLICATIONS: None
CHEST XRAY REVIEWED: Pending ***
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.mscInutbation

INTUBATION [PRO89 (Custom)]
PROCEDURE: Endotracheal Intubation
INDICATION: Hypoxic, hypercapneic respiratory failrue
CONSENT: emergent
TIME OUT: Patient was properly identified with nurse.
MEDICATIONS:  Patient already on *** versed gtt, propofol gtt
HISTORY: *** Patient required re-intubation after removal of foreign body using bronchoscope
PROCEDURE: 
The patient was pre-oxygenated by Ambu Bag Ventilation per Respiratory Therapist
Medications were given
The glidescope was used
The patient was intubated on the bed attempt using a # 8 Endotracheal Tube
Vocal Cords were visualized
The CO2 monitor was positive for color change
Breath sounds were normal bilaterally
Oxygen saturation was 100%
COMPLICATIONS: None
BLOOD LOSS: None
CHEST XRAY: *** pending
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ICD-10 Notes
- Ron Hughes as the speaker at lunch - works for a "Nuance" company
- ICD9 started in 1978
- outdated and obsolete
- inaccurate and limited data
- increasingly demonstrates lack of specificity
- must move to ICD-10 to realize EHR meaningful use
- comparison of international data is impaired
- decrease fraud and abuse
- codes - alphanumeric by anatomical site
- General
-- etiology (cause, organism, etc)
-- morphology (cell type, etc)
-- anatomy
-- manifestation - link manifestation to underlying disease
-- activity
-- injuries - injury, place, activity, states

ex: S72 - fx of femur
      - category 2500
      - site 252
      - site spec - 42
      - nature, laterality - 7
      - encounter - 1

ex: gout M10
      idiopathic M10.0
      foot M10.07
      right M10.071 


y safe way to exclude 
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.MSCDENIES - Patient denies nausea etc

DOT Phrases- About using dot phrases for labs

BRIEFLAB( ): Displays the component name, lab result, and date 
LABRCNT( ): Displays the results of recent labs performed for a patient. 
RESULTRCNT( ): component results for current and previous visits, and allows you to specify a look back time duration.
LABBRIEF( ): Displays inpatient lab results in brief.
LABRSLT( ): Displays lab results in a concise table format suitable for patient letters. The user is able to enter a list of component base or common names to include and is able to configure the column format.

BMP: BRIEFLAB(NA,K,CL,CO2,BUN,CREATININE,GLUCOSE,CALCIUM)
Last 3 BMP: LABRCNT(NA:3,K:3,CL:3,CO2:3,BUN:3,CREATININE:3,GLUCOSE:3,CALCIUM:3)



ą
AKI.png
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Marc Curvin,
Apr 21, 2015, 4:59 PM
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Marc Curvin,
Nov 2, 2015, 10:33 AM
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Marc Curvin,
Apr 21, 2015, 4:59 PM
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Marc Curvin,
Nov 18, 2015, 10:05 AM
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