{"id":3843,"date":"2025-09-14T19:20:14","date_gmt":"2025-09-14T19:20:14","guid":{"rendered":"https:\/\/nursehowie.net\/?p=3843"},"modified":"2025-09-14T19:20:14","modified_gmt":"2025-09-14T19:20:14","slug":"epic-template-fall-2025-ed","status":"publish","type":"post","link":"https:\/\/nursehowie.net\/?p=3843","title":{"rendered":"EPIC Template Fall 2025 &#8211; ED"},"content":{"rendered":"\n<p>ED Admit to Inpatient Rm<\/p>\n\n\n\n<p>ATT: @ATTPROV@<br>PCP: @PCP@<br>@NAME@ @AGE@(@BDAY@)<br>@DEPTNME@<br>@RRHLOS@<br>MRN: @MRN@<\/p>\n\n\n\n<p>Current attending in ED: @ATTPHY@<\/p>\n\n\n\n<p>SYNOPSIS<\/p>\n\n\n\n<p>@VISITINFOCC@<br>@VISITINFOHPI@<\/p>\n\n\n\n<p>@NAME@ is a @AGE@ @SEX@ ***<br>@NOTESUMMARIES(1&amp;0&amp;0)@<\/p>\n\n\n\n<p>DX:<br>@PROB@<\/p>\n\n\n\n<p>RN CONCERNS, UPDATES<\/p>\n\n\n\n<p>\u2022<\/p>\n\n\n\n<p>ASSESSMENT<\/p>\n\n\n\n<p>NEURO:<br>\u2022 Aoxo4<\/p>\n\n\n\n<p>RESPIRATORY:<br>\u2022 No SOB on room air?<br>o Supplemental Oxygen?: 14744<br>\u2022 O2 sats: @FLOWSTAT(5006:24)@<br>\u2022<\/p>\n\n\n\n<p>Blood Gases:<br>{ISTAT BLD GAS ART:16466}<\/p>\n\n\n\n<p>Vent Settings:<br>@FLOWDATI(9301)@<br>.<\/p>\n\n\n\n<p>CARDIAC:<br>\u2022<br>@EKGRESULTS@<\/p>\n\n\n\n<p>\u2022 GI:<br>o swallows pills ok<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>On Diabetic Protocol? (Assume yes if A1c > 6)<\/li>\n<\/ul>\n\n\n\n<p>@DIETORD@<\/p>\n\n\n\n<p>\u2022 last BM PTA<\/p>\n\n\n\n<p>\u2022 GU:<br>o uses urinal or purewick<br>@IOBRIEF@<\/p>\n\n\n\n<p>\u2022 SKIN\/MS:<br>o normal for ethnicity<br>o moves all extremities<br>o ambulatory:<br>o Placed on a hospital bed in ED?: yes<\/p>\n\n\n\n<p>\u2022 FAMILY:<br>o at bedside?<\/p>\n\n\n\n<p>NURSING HANDOFF<\/p>\n\n\n\n<p>NOTES ENDORSED TO RECEIVING NURSE:<br>\u2022 Controlled meds given this shift:<\/p>\n\n\n\n<p>Plan: Pending workup\/admit . All questions answered to the patient&#8217;s satisfaction. All personal belongings were with the patient including all electronics, clothing, and valuables. Pt sent w\/medical paperwork. Charge RN aware.<\/p>\n\n\n\n<p>DISPO: NAD, VSS<\/p>\n\n\n\n<p>BELONGINGS: clothing and cell phone<\/p>\n\n\n\n<p>REPORT GIVEN TO: RN<\/p>\n\n\n\n<p>TRANSPORTATION: gurney via tech<\/p>\n\n\n\n<p>DESTINATION: tbd<\/p>\n\n\n\n<p>LABS<\/p>\n\n\n\n<p>@LABRCNT24(POCGLUCOSE:*)@<\/p>\n\n\n\n<p>{SNP Linked Labs:23727}<\/p>\n\n\n\n<p>@LABBRIEF(NA,CL,BUN,K,CO2,CREATININE,GLUCOSE)@<br>@LABBRIEF(WBC,HGB,HCT,PLATELETS)@<br>@LABBRIEF(PT,INR,APTT)@<\/p>\n\n\n\n<p>@LABBRIEF(CA,MG,PHOS)@<\/p>\n\n\n\n<p>@LABBRIEF(ALB,LACTICACID,LACTWBVENPC,TROPONINHS,HGBA1C)@<\/p>\n\n\n\n<p>@LABSPENDING@<\/p>\n\n\n\n<p>@LABBRIEF(SARSCOV,INFLUENZAA)@<\/p>\n\n\n\n<p>VITALS<\/p>\n\n\n\n<p>VITALS<br>24 Hour Min \/ Max Current<br>@FLOWSTAT(6:24::1)@ @FLOW(6:last:1)@<br>@FLOWSTAT(5:24::1)@ @FLOW(5:last:1)@<br>@FLOWSTAT(8:24::1)@ @FLOW(8:last:1)@<br>@FLOWSTAT(9:24::1)@ @FLOW(9:last:1)@<br>@FLOWSTAT(10:24::1)@ @FLOW(10:last:1)@<br>Admit: @FLOW(14:first:1)@ @FLOW(14:last:1)@ @BMI@<\/p>\n\n\n\n<p>LAST VS:<br>@VS@<\/p>\n\n\n\n<p>DRIPS &amp; MEDS<\/p>\n\n\n\n<p>Scheduled Meds<br>@MEDSSCHEDULED@<\/p>\n\n\n\n<p>Home Meds<br>@MEDSSIMPLE@<\/p>\n\n\n\n<p>DRIPS &amp; CONTINUOUS IV\u2019s<\/p>\n\n\n\n<p>@CONTINUOUSMEDS@<\/p>\n\n\n\n<p>LINES:<\/p>\n\n\n\n<p>PIVs<br>\u2022<\/p>\n\n\n\n<p>IMAGING<\/p>\n\n\n\n<p>@IMAGERESULTS48H@<br>@IMAGING@<\/p>\n\n\n\n<p>NURSING PLAN<\/p>\n\n\n\n<p>Universal fall precautions are in place:<br>Orientation of the patient to the environment.<br>Explanation of call light and patient demonstration of call light use.<br>Call light attached to bedrail and within reach.<br>Gurney low, brakes locked, and both side rails up.<br>Patient&#8217;s personal possessions placed within safe reach on bedside table.<br>Adequate room lighting provided for patient to locate call bell.<br>Environment uncluttered.<br>Sitter at the bedside. Purewick in place when in indicated<br>4 Eyed Skin check done w\/2nd RN verification.<br>&nbsp;<br>In addition to the universal precautions:<br>A fall risk sign has been placed at the door of this patient&#8217;s room and a fall risk band applied to the patient.<br>A contact\/droplet sign has been placed should it be indicated (see chart).<\/p>\n\n\n\n<p>Report given to oncoming RN noted above at transfer, who then assumed all care.<\/p>\n\n\n\n<p>Howie Realubit, BSN, RN, CCRN<br>Electronic Signature<br>@TD@ @NOW@<\/p>\n","protected":false},"excerpt":{"rendered":"<p>ED Admit to Inpatient Rm ATT: @ATTPROV@PCP: @PCP@@NAME@ @AGE@(@BDAY@)@DEPTNME@@RRHLOS@MRN: @MRN@ Current attending in ED: @ATTPHY@ SYNOPSIS @VISITINFOCC@@VISITINFOHPI@ @NAME@ is a @AGE@ @SEX@ ***@NOTESUMMARIES(1&amp;0&amp;0)@ DX:@PROB@ RN CONCERNS, UPDATES \u2022 ASSESSMENT NEURO:\u2022 Aoxo4 RESPIRATORY:\u2022 No SOB on room air?o Supplemental Oxygen?: 14744\u2022 O2 sats: @FLOWSTAT(5006:24)@\u2022 Blood Gases:{ISTAT BLD GAS ART:16466} Vent Settings:@FLOWDATI(9301)@. CARDIAC:\u2022@EKGRESULTS@ \u2022 GI:o swallows pills&hellip;<\/p>\n","protected":false},"author":1,"featured_media":3500,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"om_disable_all_campaigns":false,"_uag_custom_page_level_css":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[1],"tags":[],"class_list":["post-3843","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-uncategorized"],"aioseo_notices":[],"uagb_featured_image_src":{"full":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1.jpeg",928,1232,false],"thumbnail":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-150x150.jpeg",150,150,true],"medium":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-226x300.jpeg",226,300,true],"medium_large":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-768x1020.jpeg",768,1020,true],"large":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-771x1024.jpeg",771,1024,true],"1536x1536":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1.jpeg",928,1232,false],"2048x2048":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1.jpeg",928,1232,false],"portfolio-thumb":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-500x380.jpeg",500,380,true],"woocommerce_thumbnail":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-300x300.jpeg",300,300,true],"woocommerce_single":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-600x797.jpeg",600,797,true],"woocommerce_gallery_thumbnail":["https:\/\/nursehowie.net\/wp-content\/uploads\/2025\/07\/0_0-1-100x100.jpeg",100,100,true]},"uagb_author_info":{"display_name":"Howie","author_link":"https:\/\/nursehowie.net\/?author=1"},"uagb_comment_info":4,"uagb_excerpt":"ED Admit to Inpatient Rm ATT: @ATTPROV@PCP: @PCP@@NAME@ @AGE@(@BDAY@)@DEPTNME@@RRHLOS@MRN: @MRN@ Current attending in ED: @ATTPHY@ SYNOPSIS @VISITINFOCC@@VISITINFOHPI@ @NAME@ is a @AGE@ @SEX@ ***@NOTESUMMARIES(1&amp;0&amp;0)@ DX:@PROB@ RN CONCERNS, UPDATES \u2022 ASSESSMENT NEURO:\u2022 Aoxo4 RESPIRATORY:\u2022 No SOB on room air?o Supplemental Oxygen?: 14744\u2022 O2 sats: @FLOWSTAT(5006:24)@\u2022 Blood Gases:{ISTAT BLD GAS ART:16466} Vent Settings:@FLOWDATI(9301)@. CARDIAC:\u2022@EKGRESULTS@ \u2022 GI:o swallows pills&hellip;","_links":{"self":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts\/3843","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=3843"}],"version-history":[{"count":1,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts\/3843\/revisions"}],"predecessor-version":[{"id":3844,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/posts\/3843\/revisions\/3844"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=\/wp\/v2\/media\/3500"}],"wp:attachment":[{"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=3843"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=3843"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/nursehowie.net\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=3843"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}