EPIC Note templates-David Kim
PROGRESS NOTE-OBGYN
Subjective: @NAME@ is a @AGE@ with @LMP@ with complaint of ***
@MEDICALHX@
@MEDCIP@
ROS: Negative for all systems, except for those listed above.
Objective: @VITALS@
Gen: well nourished, No apparent distress, alert & oriented x 3
Abdomen: Soft, non-tender, non-distended, no organomegaly, and no hernias
Extremity: full range of motion x 4
Neuro: normal gait
Skin: no gross lesions rashes
Assessment/Plan: @NAME@ is a @AGE@ female with complaint of ***
@DIAGMED@
ANNUAL WELL WOMAN EXAM
Patient name: @NAME@
Date of birth: @DOB@
Chief complaint: @RFVN@
HPI: @FNAME@ is a @AGE@ @SEX@ @GP@ with LMP *** who presents today for ***
Health Maintenance:
Last Pap:***
Mammogram:***
Colonoscopy:***
SURGICAL HISTORY:
@PSH@
MEDICAL HISTORY:
@PMH@
OB History:
@OBBRIEFHIST@
GYNECOLOGIC HISTORY:
SOCIAL HISTORY:
@SOC@
Narrative
@SOCDOC@
FAMILY HISTORY:
@FAMHX@
Review of systems: Negative for all systems, except those listed above.
Physical Examination:
@VITALS@
@BMI@
Gen: well nourished, No apparent distress, alert & oriented x 3
Neck: No neck masses
Breast: No breast masses, no axillary or clavicular lymphadenopathy, no nipple discharge
Lungs: Clear to auscultation bilaterally, no wheezing
Cardiac: Regular rate and rhythm, no murmurs
Abdomen: Soft, non-tender, non-distended, no organomegaly, and no hernias
Pevlic: Normal external genitalia, normal bartholin's glands, urethra, and skene's glands, normal
estrogenized vaginal mucosa, normal cervix, Uterus ** size, no adnexal masses or tenderness.
Extremity: full range of motion x 4
Neuro: normal gait
Skin: no gross lesions rashes
Assessment and Plan: This is a @AGE@ with G***P*** here for ***
@DIAGMED@
PROCEDURE-PELVIC ULTRASOUND
*** probe was used.
Uterus: *** x *** x *** cm. Volume=***
Endometrial thickness: *** mm
Comments:***
Right Ovary: *** x *** x *** cm Volume=***
Left Ovary: *** x *** x *** cm. Volume=***
Comments:***
PROCEDURE-FIRST TRIMESTER OBSTETRIC ULTRASOUND
LMP:***
EDC by dates:***
CRL=*** mm
AUA=***
EDC by ultrasound:***
Right Ovary:***
Left Ovary: ***
Comments:***
Recommendations for final EDC:***
PROCEDURE-NST/AFI ANTEPARTUM TESTING
NST:
Baseline FHR: ***
Variability: ***
Accelerations: ***
Decelerations ***
Uterine Contractions:***
Ultrasound:
AFI: ***
Deep Vertical Pocket:***
Placenta:***
Presentation***
Recommendation/Follow Up:
BIOPHYSICAL PROFILE
Amniotic Fluid:***
Breathing:***
Movement:***
Tone:***
NST:***
Total Score:***
PROCEDURE NOTE-TRIGGER POINT INJECTION OF ABDOMINAL RECTUS MUSCLE
This is Trigger Point Injection #***
Patient was consented on risks and benefits of trigger point injection, including but not limited to
risks of infection, bruising, and pain.
+Carnett test. {LOCABDOMEN:21145} ***/10 pain in supine position. ***/10 pain in sitting
position. 3 cc 1% buffered lidocaine with epinephrine injected. Post injection pain ***/10 in
supine position, and ***/10 pain in sitting position.
No complicatoins.
Follow up in *** weeks for next trigger point injection.
David S. Kim, MD, MS, MBA
PROCEDURE NOTE-ENDOMETRIAL BIOPSY
Pre-Operative Diagnosis:***
Post-Operative Diagnosis:***
Attending:***
Assistant:***
Procedure: Endometrial Biopsy
Complications: {YES/NO:21985}
Urine pregnancy test was confirmed to be negative. I consented the patient for the endometrial
biopsy procedure and discussed the following risks, benefits, and alternatives. Risks include
but are not limited to bleeding, infection, cramping, uterine perforation, and allergic reaction
(related to betadine prep). The benefit of the procedure depends on the indication for the
procedure and may be to evaluate for endometrial hyperplasia. The alternative to this
procedure include a hysteroscopy with dilation and curettage.
Patients condition is stable.
Procedure: Endometrial biopsy was performed in the usual fashion. The cervix was cleaned with
betadine. A tenaculum {WAS/NOT:19945} was used to grasp the anterior lip of the cervix.
*** passes were performed using the pipelle. *** amount of endometrial tissue was obtained.
The specimen was sent to pathology.
Impression:***
Plan:***
Discussion:***
Specimens Removed: {gen none default:314326::"none"}
David S. Kim, MD, PhD, MBA
PROCEDURE-COLPOSCOPY
HPI: @NAME@ is a @AGE@ @SEX@ here for colposcopy. .
LMP: ***
Last Pap was ***.
There {IS/IS NOT:19182} a history of tobacco use. Pregnancy test was negative.
Patient was consented for colposcopy and biopsies today. Patient was informed of risks and
benefits of this procedure. Benefits include ruling out precancer and cancer. Risks include
bleeding, cramping, pain, brown discharge. Patient was also warned to have pelvic rest x 2 wks.
Cervical Exam:
Acetic acid applied.
AW @ ***
*** lesions @
Bx's taken ***
C/W ***
Hemostasis noted
Assessment: Colpo was consistent with ***
Plan:***
David S. Kim, MD, PhD, MBA
Procedure Note: Nexplanon insertion
Patient was consented and explained risks of bleeding and infection. Patient was counseled on
side effects of headaches, irregular unpredictable vaginal spotting up to 6 mo's duration, and
amenorrhea in some women.
The non dominant left arm was betadined x 3 to clean the area. Approximately 10 cm from the
left medial epicondyle 1-2 cc of 1% lidocaine with epinephrine was injected at the site where the
Nexplanon was planned to be inserted.
The Nexplanon was examined and confirmed to have the etonogestrel implant in the loading
needle. The Nexplanon rod was inserted into the targed area of the skin subdermally in the left
arm and deployed without complications. Steristrips were placed over the small incision. The
arm was then wrapped in an elastic wrap to reduce bruising.
RTC in 2 weeks for Nexplanon follow up check. Patient counseled to use condoms for 1 week.
David S. Kim, MD, PhD, MBA
Procedure Note: Saline Infusion Sonography
Pre-Operative Diagnosis:
Post-Operative Diagnosis:
Attending: ***
Assistant:***
Procedure: Saline Infusion Sonography
Complications: None
A time out was performed. Urine pregnancy test was confirmed to be negative. I consented the
patient for the saline sonogram procedure and discussed the following risks, benefits and
alternatives. Risks include but are not limited to bleeding, infection, cramping, and allergic
reaction (related to betadine prep). It is also possible that the procedure is suboptimal and/or
non-diagnostic and further work-up is required. The benefit of the procedure is to identify
uterine abnormalities such as polyps, submucosal fibroids, or scar tissue as it relates to infertility
or recurrent pregnancy loss. The alternative to this procedure include a diagnostic
hysteroscopy.
Procedure: Saline sonogram was performed in the usual fashion. Speculum was inserted.
Cervix cleaned with betadine. Saline catheter inserted into cervical os. Normal saline *** cc
injected. Findings described below. Patient tolerated the procedure well.
Findings: ***
Impression: ***
Plan: ***
Discussion:***
David S. Kim, MD, PhD, MBA
Physical Exam-full
Gen: well nourished, No apparent distress, alert & oriented x 3
Neck: No neck masses
Breast: No breast masses, no axillary or clavicular lymphadenopathy, no nipple discharge
Lungs: Clear to auscultation bilaterally, no wheezing
Cardiac: Regular rate and rhythm, no murmurs
Abdomen: Soft, non-tender, non-distended, no organomegaly, and no hernias
Pevlic: Normal external genitalia, normal bartholin's glands, urethra, and skene's glands, normal
estrogenized vaginal mucosa, normal cervix, Uterus ** size, no adnexal masses or tenderness.
Extremity: full range of motion x 4
Neuro: normal gait
Skin: no gross lesions rashes
Physical Exam-limited
Gen: well nourished, No apparent distress, alert & oriented x 3
Abdomen: Soft, non-tender, non-distended, no organomegaly, and no hernias
Extremity: full range of motion x 4
Neuro: normal gait
Skin: no gross lesions rashes