Autotext Dot Phrases for Cerner EHR

All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Do not merely copy and paste a prewritten note element into a patient's chart - "cloning" is unethical, unsafe, and potentially fradulent.

 
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Preoperative Risk Assessment for Major Adverse Cardiac Event

Perioperative risk assessment for MACE:

Patient’s likelihood of coronary artery disease is:

_ Low Intermediate High

Based on the following Risk factors:

_ DM HTN Hyperlipids Tobacco use within 15 years FHx of CAD Postmenopausal

Patient is with the following exercise tolerance:

_ Poor/1 MET (Examples: can perform ADLs, walk indoors around house, walk on level ground at 2 mph, light housework, wash dishes)

_ Fair/4 METs (Examples: Climb one flight of stairs, Walk on level ground at 4 mph, Run a short distance, Vacuum, lift furniture, Golf, doubles tennis, dancing)

_ Excellent/10 METs (Examples: Swimming, Running, Singles tennis, Basketball, Skiing)

Patient is awaiting the following risk surgery:

_ Low (<1% of a MACE) (Examples: Cataract, Breast lumpectomy, Endoscopy, Superficial biopsy)

_ Intermediate (1-5% of a MACE) (Examples: Carotid endarterectomy, Peripheral vascular (infrainguinal), Head and neck, Orthopedic, Abdominal/GYN, Urologic, Thoracic)

_ High (>5% of a MACE) (Examples: Emergency (esp. elderly), Extensive w large volume shifts, Prolonged surgery (>5 hrs), Most neurosurgery, Aortic/Peripheral vascular (suprainguinal))

Type of surgery:

  • Emergent: Life or limb threat if no surgery <6 hours

  • Urgent: Life or limb threat if no surgery within 6 - 24 hours

  • Time Sensitive: Delay of surgery for >6 weeks will negatively affect outcome

  • Elective: Surgery could be delayed up to 1 year without harm

_ Patient with no active cardiac conditions defined as:

_ Patient with the following active cardiac conditions:

-Recent MI (7 to 30 days) with evidence of ischemic risk on basis of clinical symptoms or results of noninvasive studies

-Unstable or severe angina (including stable angina among patients unusually sedentary, DOE)

-Marked arrhythmias (eg. with hemodynamic instability, high-degree heart block, symptomatic VT, SVT w uncontrolled rate (HR>100)

-Severe valvular disease (eg. AS with valve area <1 cm² or symptomatic MS)

_Patient with none of the following clinical risk factors:

_Patient with the following clinical risk factors:

-Hx of heart disease

-Hx of CVA, TIA

-Compensated /prior CHF

-DM

-CKD (Cr ≥ 2)

_ No RCRI indicators listed below are present:

_ RCRI indicators that are present are:

-High risk surgery

-CAD (angina or CP better w/ NTG, remote MI >3-6 months, path q wave, etc)

-Hx of CVA, TIA

-Hx of CHF

-DM requiring insulin

-CKD (Cr ≥ 2)

-Intrabdominal or high risk surgery

Giving the patient a RCRI score of:

[ ] 0 (0.4%) [ ] 1 (0.9%) [] 2 (6.6%) []≥ 3 (11%)

_Gupta Cardiac Risk:

http://www.qxmd.com/calculate-online/cardiology/gupta-perioperative-cardiac-risk

_ACS NSQIP Surgical Risk Calculator Risk:

http://riskcalculator.facs.org/

Therefore, based on the 2014 ACC/AHA Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery combined with the above calculated risks for MACE, I recommend:

_ That the patient may proceed to surgery without further cardiovascular risk stratification

_ That the patient requires further cardiovascular risk stratification: _

_ Perioperative medications are not indicated. Please continue chronic medications and hold those recommended by the surgeon for the timeframe the surgeon recommends.

_ Perioperative B-Blockade if:

  • >/= RCRI 3 (IIb-C)

  • < RCRI 3 + (CAD, HF, HTN) (IIb-B)

  • Start >1 day early to a goal resting HR of 60

  • I will start the patient on _

_ Perioperative Statin if:

  • Consider in high risk procedure (IIb-c)

  • Vascular Surgery (IIa-B)

  • Continue if already on statin (I-B)

  • I will start the patient on _

_ Perioperative Alpha blocker (III-B) No benefit, not indicated unless BP/HR failed on BB

_ That the patient receive endocarditis PPx of:

_ In regards to Diabetic meds, if NPO:

Orals: Hold

Insulin: Hold short acting insulin the morning of the procedure. Use half the long acting insulin the night before or morning of the procedure

_ In regards to antiplatelet/anticoagulation medications:

Hold aspirin 7 days prior to the procedure, resume when OK with surgeon

Others:

_ Stress dose steroids:

That the patient receive DVT PPx per the surgeon if indicated

That the patient use an incentive spirometer post-op if indicated by the surgeon

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