Copy - EMR Template (COPY ME)

DO NOT EDIT W/O DULPLICATING

COPY ME

1) In the = (3 line) menu in the upper right corner, select "create a copy of your genially" (may want to create a couple of copies for yourself). 2) Edit as you see fit, but remember formatting should (ideally) be consistent. 3) Delete these gray boxes after reading instructions

Instructions

How do I get the patient information on each slide? It's such a pain! Best approach is to: Change the information on the summary screen (this screen!) the way you want it. Then ctrl+c to copy it. Go to each slide after this and left click + drag to copy all of the left panel demographic content and delete it. Then press ctrl+v and it should paste it in the correct location. Take 30 seconds to do this for all slides. It's fast. I promise.

Allergies

Progress Note January 11

Progress Note January 11

Allergies

Progress Note January 11

Long Note Example January 11

1) To add more notes, copy one of the current notes and paste it where you'd like. 2) Each of these is clickable and has a Window that will appear when clicked. 3) Edit the window by left clicking the note you want to edit and selecting "Window" then "edit" in black in the lower right window that appears. 4) The upper left has a "back to page" button to get out of the window view.

Instructions

History and Physical January 11

Allergies

CBC | Cardiac Panel

Arterial Blood Gases

Other

Coagulation Studies

Iron | Lipids | Urinalysis

BMP/CMP | Coag | ABGs

Basic Metabolic Panel

+Complete Metabolic Panel

1) I recommend keeping table formatting essentially the same. Avoid the headache of deleting rows and instead just delete the text from the row. Do what works best for you.

Instructions

Allergies

CBC | Cardiac Panel

Arterial Blood Gases

Other

Coagulation Studies

Iron | Lipids | Urinalysis

BMP/CMP | Coag | ABGs

Basic Metabolic Panel

+Complete Metabolic Panel

The blue buttons are an example of what you could do to create a learning-focused case instead of an assessment-focused case. Delete them if you don't want them.

Instructions

Allergies

CBC (w/ differential)

CBC | Cardiac Panel

Other

Iron | Lipids | Urinalysis

BMP/CMP | Coag | ABGs

CardiacPanel

CBC (w/ differential)

Allergies

Urinalysis

CBC | Cardiac Panel

Other

Iron | Lipids | Urinalysis

BMP/CMP | Coag | ABGs

LipidPanel

IronStudies

Allergies

CBC | Cardiac Panel

Other

Iron | Lipids | Urinalysis

BMP/CMP | Coag | ABGs

Allergies

Infectious Disease

CXR 1/12 | 6:00

Imaging

CXR 1/12 | 6:00

CXR 1/12 | 6:00

Culture and Sensitivity 1/12 | 6:00

Culture and Sensitivity 1/12 | 6:00

Allergies

The activities screen is not necessary unless you want to create a learning-focused case. Just delete the content here if you do not plan to use (but leave the activities tab/screen alone!) When edits are all done, click on the Add collaborators icon ( ) and add "slperk86@gmail.com"

Instructions

Allergies

00:30

History and Physical

EG TESTING PROGRESS NOTE Jan 11 Name: Laura Winslow Age: 37 years Sex: Female Chief Complaint: Shortness of breath, swelling, and fatigue History of Present Illness: Laura Winslow is a 37-year-old Caucasian female who presents to the Emergency Department (ED) with complaints of increasing shortness of breath, fatigue, and weakness over the past 2 days. She reports feeling fatigued even while sitting down. The symptoms have progressively worsened and are not relieved with rest. She also notes swelling in her legs, which has become more pronounced. On physical examination, she has 2+ pitting edema in her lower extremities. Based on her clinical presentation and history, she is diagnosed with a heart failure exacerbation. Past Medical History: Mrs. Winslow has a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. Medications: Carvedilol 25 mg twice daily Lisinopril 40 mg daily Simvastatin 40 mg every night Aspirin 81 mg daily Metformin 1000 mg twice daily Levothyroxine 75 mcg daily Furosemide 40 mg PO BID Allergies: Bactrim (hives) Social History: Mrs. Winslow lives with her husband, who assists with daily activities. She drinks alcohol occasionally (1-2 drinks). Denies illicit drug use. Family History: Mrs. Winslow's father died at age 75 from a heart attack 7 years ago. Mom is still alive. Physical Examination: Vital Signs: Blood pressure: 152/90 mmHg; Heart rate: 70 beats per minute; Respiratory rate: 18 breaths per minute; Temperature: 98.96°F (37.2°C);Oxygen saturation: 95% on room air General Appearance: Mrs. Winslow appears alert and oriented. Cardiovascular: Some jugular venous pressure noted. Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. Musculoskeletal: Pulses are absent in both feet. There is decreased sensation to light touch and pinprick in both lower extremities. No muscle atrophy or weakness is noted. Skin: No ulcerations or discoloration is noted. Assessment: Mrs. Winslow is a 37-year-old female with a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. She presents with heart failure exacerbation with worsening symptoms of dyspnea, fatigue, and edema. Her hypertension and type 2 diabetes mellitus is poorly controlled. Plan: CHF, HTN: Continue aspirin and statin Begin IV diuretics for edema T2DM: Hold home metformin; Start sliding scale insulin; Follow up A1c

Go to a website to learn more?

Hand X-ray

Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.

Culture and Sensitivity

Campbell Laboratories, LLG Buies Creek, NC 27506

History and Physical

EG TESTING PROGRESS NOTE Jan 11 Name: Laura Winslow Age: 37 years Sex: Female Chief Complaint: Shortness of breath, swelling, and fatigue History of Present Illness: Laura Winslow is a 37-year-old Caucasian female who presents to the Emergency Department (ED) with complaints of increasing shortness of breath, fatigue, and weakness over the past 2 days. She reports feeling fatigued even while sitting down. The symptoms have progressively worsened and are not relieved with rest. She also notes swelling in her legs, which has become more pronounced. On physical examination, she has 2+ pitting edema in her lower extremities. Based on her clinical presentation and history, she is diagnosed with a heart failure exacerbation. Past Medical History: Mrs. Winslow has a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. Medications: Carvedilol 25 mg twice daily Lisinopril 40 mg daily Simvastatin 40 mg every night Aspirin 81 mg daily Metformin 1000 mg twice daily Levothyroxine 75 mcg daily Furosemide 40 mg PO BID Allergies: Bactrim (hives) Social History: Mrs. Winslow lives with her husband, who assists with daily activities. She drinks alcohol occasionally (1-2 drinks). Denies illicit drug use. Family History: Mrs. Winslow's father died at age 75 from a heart attack 7 years ago. Mom is still alive. Physical Examination: Vital Signs: Blood pressure: 152/90 mmHg; Heart rate: 70 beats per minute; Respiratory rate: 18 breaths per minute; Temperature: 98.96°F (37.2°C);Oxygen saturation: 95% on room air General Appearance: Mrs. Winslow appears alert and oriented. Cardiovascular: Some jugular venous pressure noted. Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. Musculoskeletal: Pulses are absent in both feet. There is decreased sensation to light touch and pinprick in both lower extremities. No muscle atrophy or weakness is noted. Skin: No ulcerations or discoloration is noted. Assessment: Mrs. Winslow is a 37-year-old female with a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. She presents with heart failure exacerbation with worsening symptoms of dyspnea, fatigue, and edema. Her hypertension and type 2 diabetes mellitus is poorly controlled. Plan: CHF, HTN: Continue aspirin and statin Begin IV diuretics for edema T2DM: Hold home metformin; Start sliding scale insulin; Follow up A1c

Name: Laura Winslow Age: 37 years Sex: Female Chief Complaint: Shortness of breath, swelling, and fatigue History of Present Illness: Laura Winslow is a 37-year-old Caucasian female who presents to the Emergency Department (ED) with complaints of increasing shortness of breath, fatigue, and weakness over the past 2 days. She reports feeling fatigued even while sitting down. The symptoms have progressively worsened and are not relieved with rest. She also notes swelling in her legs, which has become more pronounced. On physical examination, she has 2+ pitting edema in her lower extremities. Based on her clinical presentation and history, she is diagnosed with a heart failure exacerbation. Past Medical History: Mrs. Winslow has a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. Medications: Carvedilol 25 mg twice daily Lisinopril 40 mg daily Simvastatin 40 mg every night Aspirin 81 mg daily Metformin 1000 mg twice daily Levothyroxine 75 mcg daily Furosemide 40 mg PO BID Allergies: Bactrim (hives) Social History: Mrs. Winslow lives with her husband, who assists with daily activities. She drinks alcohol occasionally (1-2 drinks). Denies illicit drug use. Family History: Mrs. Winslow's father died at age 75 from a heart attack 7 years ago. Mom is still alive. Physical Examination: Vital Signs: Blood pressure: 152/90 mmHg; Heart rate: 70 beats per minute; Respiratory rate: 18 breaths per minute; Temperature: 98.96°F (37.2°C);Oxygen saturation: 95% on room air General Appearance: Mrs. Winslow appears alert and oriented. Cardiovascular: Some jugular venous pressure noted. Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. Musculoskeletal: Pulses are absent in both feet. There is decreased sensation to light touch and pinprick in both lower extremities. No muscle atrophy or weakness is noted. Skin: No ulcerations or discoloration is noted. Assessment: Mrs. Winslow is a 37-year-old female with a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. She presents with heart failure exacerbation with worsening symptoms of dyspnea, fatigue, and edema. Her hypertension and type 2 diabetes mellitus is poorly controlled. Plan: CHF, HTN: Continue aspirin and statin Begin IV diuretics for edema T2DM: Hold home metformin; Start sliding scale insulin; Follow up A1c

History and Physical

TEST LONG NOTE EXAMPLE EDIT Name: Laura Winslow Age: 37 years Sex: Female Chief Complaint: Shortness of breath, swelling, and fatigue History of Present Illness: Laura Winslow is a 37-year-old Caucasian female who presents to the Emergency Department (ED) with complaints of increasing shortness of breath, fatigue, and weakness over the past 2 days. She reports feeling fatigued even while sitting down. The symptoms have progressively worsened and are not relieved with rest. She also notes swelling in her legs, which has become more pronounced. On physical examination, she has 2+ pitting edema in her lower extremities. Based on her clinical presentation and history, she is diagnosed with a heart failure exacerbation. Past Medical History: Mrs. Winslow has a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. Medications: Carvedilol 25 mg twice daily Lisinopril 40 mg daily Simvastatin 40 mg every night Aspirin 81 mg daily Metformin 1000 mg twice daily Levothyroxine 75 mcg daily Furosemide 40 mg PO BID Allergies: Bactrim (hives) Social History: Mrs. Winslow lives with her husband, who assists with daily activities. She drinks alcohol occasionally (1-2 drinks). Denies illicit drug use. Family History: Mrs. Winslow's father died at age 75 from a heart attack 7 years ago. Mom is still alive. Physical Examination: Vital Signs: Blood pressure: 152/90 mmHg; Heart rate: 70 beats per minute; Respiratory rate: 18 breaths per minute; Temperature: 98.96°F (37.2°C);Oxygen saturation: 95% on room air General Appearance: Mrs. Winslow appears alert and oriented. Cardiovascular: Some jugular venous pressure noted. Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. Musculoskeletal: Pulses are absent in both feet. There is decreased sensation to light touch and pinprick in both lower extremities. No muscle atrophy or weakness is noted. Skin: No ulcerations or discoloration is noted. Assessment: Mrs. Winslow is a 37-year-old female with a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. She presents with heart failure exacerbation with worsening symptoms of dyspnea, fatigue, and edema. Her hypertension and type 2 diabetes mellitus is poorly controlled. Plan: CHF, HTN: Continue aspirin and statin Begin IV diuretics for edema T2DM: Hold home metformin; Start sliding scale insulin; Follow up A1c

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TEST IMAGING NOTE

DESCRPTION/INTERPRETATION IMAGING HERE

History and Physical

TEST H&P EDIT Jan 11 Name: Laura Winslow Age: 37 years Sex: Female Chief Complaint: Shortness of breath, swelling, and fatigue History of Present Illness: Laura Winslow is a 37-year-old Caucasian female who presents to the Emergency Department (ED) with complaints of increasing shortness of breath, fatigue, and weakness over the past 2 days. She reports feeling fatigued even while sitting down. The symptoms have progressively worsened and are not relieved with rest. She also notes swelling in her legs, which has become more pronounced. On physical examination, she has 2+ pitting edema in her lower extremities. Based on her clinical presentation and history, she is diagnosed with a heart failure exacerbation. Past Medical History: Mrs. Winslow has a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. Medications: Carvedilol 25 mg twice daily Lisinopril 40 mg daily Simvastatin 40 mg every night Aspirin 81 mg daily Metformin 1000 mg twice daily Levothyroxine 75 mcg daily Furosemide 40 mg PO BID Allergies: Bactrim (hives) Social History: Mrs. Winslow lives with her husband, who assists with daily activities. She drinks alcohol occasionally (1-2 drinks). Denies illicit drug use. Family History: Mrs. Winslow's father died at age 75 from a heart attack 7 years ago. Mom is still alive. Physical Examination: Vital Signs: Blood pressure: 152/90 mmHg; Heart rate: 70 beats per minute; Respiratory rate: 18 breaths per minute; Temperature: 98.96°F (37.2°C);Oxygen saturation: 95% on room air General Appearance: Mrs. Winslow appears alert and oriented. Cardiovascular: Some jugular venous pressure noted. Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. Musculoskeletal: Pulses are absent in both feet. There is decreased sensation to light touch and pinprick in both lower extremities. No muscle atrophy or weakness is noted. Skin: No ulcerations or discoloration is noted. Assessment: Mrs. Winslow is a 37-year-old female with a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. She presents with heart failure exacerbation with worsening symptoms of dyspnea, fatigue, and edema. Her hypertension and type 2 diabetes mellitus is poorly controlled. Plan: CHF, HTN: Continue aspirin and statin Begin IV diuretics for edema T2DM: Hold home metformin; Start sliding scale insulin; Follow up A1c

Go to a website to learn more?

Hand X-ray

Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.

Go to a website to learn more?

Hand X-ray

Interpretation: Ouchie! That hand hurt. But it's probably fine based on this X-ray.

History and Physical

EG TESTING PROGRESS NOTE Jan 11 Name: Laura Winslow Age: 37 years Sex: Female Chief Complaint: Shortness of breath, swelling, and fatigue History of Present Illness: Laura Winslow is a 37-year-old Caucasian female who presents to the Emergency Department (ED) with complaints of increasing shortness of breath, fatigue, and weakness over the past 2 days. She reports feeling fatigued even while sitting down. The symptoms have progressively worsened and are not relieved with rest. She also notes swelling in her legs, which has become more pronounced. On physical examination, she has 2+ pitting edema in her lower extremities. Based on her clinical presentation and history, she is diagnosed with a heart failure exacerbation. Past Medical History: Mrs. Winslow has a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. Medications: Carvedilol 25 mg twice daily Lisinopril 40 mg daily Simvastatin 40 mg every night Aspirin 81 mg daily Metformin 1000 mg twice daily Levothyroxine 75 mcg daily Furosemide 40 mg PO BID Allergies: Bactrim (hives) Social History: Mrs. Winslow lives with her husband, who assists with daily activities. She drinks alcohol occasionally (1-2 drinks). Denies illicit drug use. Family History: Mrs. Winslow's father died at age 75 from a heart attack 7 years ago. Mom is still alive. Physical Examination: Vital Signs: Blood pressure: 152/90 mmHg; Heart rate: 70 beats per minute; Respiratory rate: 18 breaths per minute; Temperature: 98.96°F (37.2°C);Oxygen saturation: 95% on room air General Appearance: Mrs. Winslow appears alert and oriented. Cardiovascular: Some jugular venous pressure noted. Regular rhythm with no murmurs or gallops heard. Respiratory: Lungs are clear to auscultation bilaterally. Abdomen: Soft, no abdominal tenderness or distention. No hepatosplenomegaly or masses palpated. Musculoskeletal: Pulses are absent in both feet. There is decreased sensation to light touch and pinprick in both lower extremities. No muscle atrophy or weakness is noted. Skin: No ulcerations or discoloration is noted. Assessment: Mrs. Winslow is a 37-year-old female with a history of peripheral arterial disease, hypertension, hyperlipidemia, heart failure with reserved ejection fraction, hypothyroidism, and type 2 diabetes. She presents with heart failure exacerbation with worsening symptoms of dyspnea, fatigue, and edema. Her hypertension and type 2 diabetes mellitus is poorly controlled. Plan: CHF, HTN: Continue aspirin and statin Begin IV diuretics for edema T2DM: Hold home metformin; Start sliding scale insulin; Follow up A1c

Culture and Sensitivity

Campbell Laboratories, LLG Buies Creek, NC 27506