Templates

To make a template in eMR, open a note (and click somewhere to type) > Manage Auto Text (far-right of bar) > Blue Plus (top-left). To autofill values, Insert Templates/Tokens > Search for what you want. Abbreviation is the shortcut to insert your templates - we recommend abbreviations starting with @ to avoid accidentally inserting a template (e.g. @ward_round).

eMR Proformas

Order Sets

Cannula Review

VIPS0

Flushes well

Plan

Cannula to remain in-situ, continue using

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VIPS (Visual Infusion Phlebitis Score)

0 No phlebitis → Observe cannula

1 Slight pain OR slight erythema → Observe cannula

2 Two of pain/erythema/swelling → Resite

3 All of pain/erythema/swelling → Resite ± treat

4 Extensive 3/palpable venous cord/pyrexia) → Resite ± treat

5 All & extensive 4 → Resite + treat

Name (JMO)

#123

Death Certification

Assessment

Identity confirmed from wrist band

Patient in bed, no signs of life

No respiratory effort noted

No response to verbal stimuli

No response to central painful stimuli

No carotid pulse palpable

Pupils fixed and dilated bilaterally

No heart sounds heard during 5 minutes of auscultation

No breath sounds heard during 5 minutes of auscultation

Death confirmed at TIME on DATE

Plan

Cremation Risk Advice completed

Coronial Checklist: home team to kindly complete (ideally do this too if time permitting)

Medical Certificate of Cause of Death: home team to kindly complete (do if home team documented expected cause of death or advised by consultant when notifying)

Consultant notified/to be notified in the morning

Family notified

May they rest in peace

Name (JMO)

Admission date:

Discharge date:

AMO: Dr Specialty Specialist (Specialty)

Discharge destination: Home

Principal diagnosis: Headache

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Summary of Admission

NAME is a AGE-year-old GENDER who presented to St George Hospital with

Issues during Admission

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Discharge Plan

1. Discharge to home

2. Medications

- NEW

- CHANGED

- CEASED

- Please continue taking your regular medications as previously prescribed

3. Please follow-up with your GP in 3-5 days - GP to kindly:

- Prescribe medications and review changes as detailed

- Provide referral

4. Follow-up with Dr X at PLACE on DATE (or approximation)

- You will be contacted by the hospital (likely a private number) with appointment details. Please contact (02) XXXX XXXX if you have not heard from the hospital in 4 weeks.

5. If you have new or worsening symptoms or concerns, please see your GP or present to the nearest Emergency Department.

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Past Medical History

Social History

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Thank you and kind regards,

Dr YOUR NAME

TEAM Intern

On behalf of Dr AMO NAME (Specialist)

St George Hospital

(02) 9113 1111, pager #

Sensation: intact UL + LL L=R

Tone: intact UL + LL L=R, no clonus

Power R L

- Shoulder abduction C5-6 5 5

- Shoulder adduction C6-8 5 5

- Elbow flexion C5-6 5 5

- Elbow extension C7-8 5 5

- Wrist flexion C6-7 5 5

- Wrist extension C7-8 5 5

- Finger flexion C7-8 5 5

- Finger extension C7-8 5 5

- Finger abduction C8-T1 5 5

- Finger adduction C8-T1 5 5

- Hip flexion L1-3 5 5

- Hip extension L4-5 5 5

- Hip abduction L2-4 5 5

- Hip adduction L4-S2 5 5

- Knee flexion L5-S2 5 5

- Knee extension L3-4 5 5

- Ankle dorsiflexion L4-5 5 5

- Ankle plantarflexion S1-2 5 5

Reflexes R L

- Biceps C5-6 + +

- Triceps C7-8 + +

- Brachioradialis C5-6 + +

- Knee L3-4 + + - Ankle S1-2 + +

- Babinski (↑/↓) L5-S1 ↓ ↓

Cerebellar

Pronator drift NAD bilaterally

Dysdiadochokinesia NAD bilaterally

Dysmetria NAD bilaterally

Heel-shin NAD bilaterally

Foot tapping NAD bilaterally

Gait

- Walking Normal

- Tandem Normal

- Heels Normal

- Toes Normal

Pre-Admission Clinic

[ Age ] [ Gender ] [ 3019_reason_for_visit ]

Planned Operation

OPERATION for PROBLEM under Dr CONSULTANT on PLANNED DATE

HPC

Brief summary for future reference, they've already been worked up in outpatients

PMHx

[ MH_Past_Medical_Hx_ST ]

Meds

[ * Medication List ]

Allergies

[ Allergies ]

PSHx

Investigations

Scans: what, where, when, do they need a more recent scan?

Plan

Please bring with you any scans, letters or health records to hospital

Medications and fasting as per anaesthetics

Call the hospital if you develop flu/COVID-like symptoms

Name (JMO)

(Reg) / (JMO) / Casey (CNC) - if Erin Casey is there!

Stroke Call

Time of stroke call:

Time of arrival to ED:

Last seen well:

NIHSS:

Time to scanner:

Time to thrombolysis:

History of Presenting Complaint

Past Medical History

[ Medication History (eMeds) ]

Medications

[ * Medication List ]

Allergies

[ Allergies ]

Social History

Examination

[ 3019_vital_signs_ab_flag ]

NIHSS:

1a.

1b.

1c.

5a.

5b.

6a.

6b.

10.

11.

1a. Consciousness

[0] alert

[1] arouses to minor stimulation

[2] repeated stimulation to arouse OR movement to pain

[3] postures/unresponsive

1b. Month & Age

[0] both right

[1] one right or dysarthric/intubated/trauma/language barrier

[2] none right/aphasia

1c. Blink eyes & Squeeze hands

[0] both right

[1] one right

[2] none right

2. Horizontal eye movements

[0] normal

[1] partial gaze palsy that can be overcome/corrects with oculocephalic reflex

[2] forced gaze palsy that cannot be overcome

3. Visual fields

[0] normal

[1] partial hemianopia

[2] complete hemianopia

[3] bilateral hemianopia/blindness

4. Facial palsy (grimace if obtunded)

[0] normal

[1] minor (flat nasolabial, partial smile asymmetry)

[2] partial paralysis of lower face

[3] complete paralysis

5a. L UL drift

5b. R UL drift

6a. L LL drift

6b. R LL drift

[0] nil (or amputation/joint fusion)

[1] drift, doesn't hit bed

[2] drift, hits bed OR some effort against gravity

[3] no effort against gravity

[4] no movement

7. Limb ataxia (finger-nose, heel-shin)

[0] no ataxia OR doesn't understand/paralysed/amputation/joint fusion

[1] in one limb

[2] in two limbs

8. Sensation

[0] normal

[1] less sharp but can sense being touched

[2] cannot sense/no response/coma

9. Dysphasia (describe a picture, name items, read sentences)

[0] normal

[1] mild-mod (obvious change without significant limitation)

[2] severe (fragmented, inference needed, cannot identify items)

[3] mute/no comprehension/gibberish/coma

10. Dysarthria

[0] normal/intubated/unable to test

[1] slurring but understood

[2] unintelligble slurring or out of proportion to dysphasia/mute

11. Inattention/extinction

[0] normal

[1] one of visual/tactile/auditory/spatial/personal inattention or bilateral inattention

[2] profound hemi-inattention (e.g. doesn't recognise own hand) or 1+ modality involved

Investigations

Impression

Plan

Name (JMO)

Nil fever / chills / rigors / sweats / anorexia / weight loss / fatigue

Nil headache / dizziness / change in vision/hearing/taste/smell

Nil weakness / paraesthesias / numbness

Nil photophobia / phonophobia / neck pain / neck stiffness

Nil rhinorrhoea / anosmia / sore throat / post-nasal drip / sinus pain / otalgia

Nil chest pain / SOB / palpitations / syncope / cough

Nil abdo pain / nausea / vomiting / constipation / diarrhoea / blood in stools / mucus in stools

Nil dysuria / urinary frequency / urinary urgency

Well's Score for DVT: /9 <4 D dimer, ≥4 CTPA

0/1 Active cancer (treatment/palliation <6mo)

0/1 Bedridden >3d OR major surgery <12w

0/1 Calf swelling >3cm compared to other leg (10cm below tibial tuberosity)

0/1 Collateral (nonvaricose) superficial veins present

0/1 Entire leg swollen

0/1 Localised tenderness along deep venous system

0/1 Pitting oedema confined to symptomatic leg

0/1 LL paralysis/paresis/recent plaster

0/1 Previous DVT

0/-2 Alternative diagnosis as/more likely

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Templates

Cannula Review

Cranial Nerve Exam

CURB-65

Death Certification

Discharge Summary

ED

GCS

General Exam

Neuro Exam (formats correctly on eMR)

PERC (PE Rule-out Criteria)

Pre-Admission Clinic

Primary Survey

Review (for After Hours)

Secondary Survey

SMART-COP

Stroke Call

Stroke workup

Systems Review

Vitals

Ward Round

Warfarin Charting

Well's Score for DVT

Well's Score for PE

Celecoxib

Ibuprofen

Metoclopramide

Panadeine Forte

Paracetamol