When you log into epic
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Should be under ZZ-PHYSICAL MED REHAB
I will share three lists with you
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Our patient list—> LERNER
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Rehab Floor→ 2 Warner
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Consults→ Rehab consults

Open patients chart
Find the rounding button, most likely hidden in the top down pointing triangle


Here the note template will pop up
Make sure the plan and physical exam are up to date.
Our notes are similar to general medical notes except
See example.
Plan:
1. Is usually cleared for therapy ( unless the patient is unstable) . I find it easiest to look at the medication list and attach a medication to an active problem. This will also give you a chance to notice if medications are up to date or about to expire.
Today's problem→ write : see above
The Subjective goes where Time seen is. Delete that and write patient issues of the day. I do my best to avoid writing NO issues overnight or else insurance will question why the patient is still in rehab.
If I take over your note that means the note was not accurate i.e plan did not reflect most recent medication . Physical exam not up to date i.e foley in place when foley has been removed.
After we are done rounding and complete floor notes we start consults.


Consults
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Go to the consult list
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Find the patient and double click to open
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Find the consult tab, can be hidden at the top. Do not click the square box at the top . Then the patient will fall off the consult list.
Click on the progress note or F2 and chose middle selection MSMC PMR progress Note

Also make make the service (Red Star) has Physical Medicine


CHIEF COMPLAINT:
DO NOT PUT ER Compliant
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Free Type Medical problem
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I.E. CVA, s/p CABG, Fracrture
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Add rehab diagnosis
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Weakness
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Decrease endurance
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Decline in function
REASON FOR CONSULT
John Doe was seen in consultation for rehabilitation evaluation, assessment and treatment at Mount Sinai Medical Center.
{Is this a Stroke Patient consult?:15000034} Always Delete







Example:
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Live in a house with family
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Flight of stairs to navigate
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Used a rolling walker for mobility
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Retired electrician
After HPI complete scroll down to Home environment
Here we try and answer:

Review of systems
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Can delete the template
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I use the smart prase .LLROS, adjust as needed
Physical Exam
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F2 to open it
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Click on the vitals the can use the smart phrase LLPHY
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Adjust as needed

Next is Assessment and Plan
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Update problem list
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Plan Template .LLCP→ edit the plan according to the patient. Add medical problems and treatment

Last part of the note is called the pre admission screen which is required by insurances.
F2 to work through this part