Disclaimer: These are sample templates, intended to be individualized by practicing medical professionals and do not constitute diagnostic or treatment recommendations.

They do not reflect the views or endorsement of my institution.

Now, Go Save Lives. -Dr. Kat Zechar

COVID NOTE: Assessment

This patient is being evaluated for COVID-19, possible Coronavirus (SARS CoV-2) Infection reports the following symptoms/risk factors:

Symptoms: Smartlist: Choose Multiple

Measured Fever over 100.4

Subjective Fever, not measured

Cough

Dyspnea

Confirmed COVID patient contact without PPE

High Risk COVID patient contact without PPE

Low Risk COVID patient contact (was wearing PPE)

International Travel

Domestic Travel

Low clinical risk symptoms (Sore Throat, GI upset)

This patient has been determined to be {DESC; LOW/MEDIUM/HIGH:26590} risk for COVID-19

This patient {HAS HAS NOT:18834} been tested for Coronavirus (SARS CoV-2).

Date and Method of Testing (if applicable): ***

Patient’s Code Status Is: @CODESTATUS@

Pertinent COVID Testing:

CXR/CT findings: ***

Inflammatory Markers

@RESUFAST(DDIMER,FERRITIN)@

@CRP@

CBC and LFTs

@LABRCNTIP(wbc:3,hgb:3,LYMPHOPCT:3)@

Does the patient have leukopenia? {YES NO:20877}

@LABRCNTIP(alkphos:3,bilitot:3,bilidir:3,prot:3,labalbu:3,alt:3,ast:3)@

@LABRCNTIP(aptt:3,inr:3,ptt:3)@

Cardiac and Renal Markers

@RESUFAST(CKTOTAL,CKMB,CKMBINDEX,TROPONINI)@

@LABRCNTIP(creatinine:3)@

Culture Data

@RESULAST(BLOODCX,URINECX,CSFCX,AFBCX)@

COVID DISCHARGE DOT PHRASE

This patient has been evaluated for COVID-19, possible Coronavirus (SARS CoV-2) Infection and reports the following symptoms/risk factors:

Symptoms: Smartlist: Choose Multiple

Measured Fever over 100.4

Subjective Fever, not measured

Cough

Dyspnea

Confirmed COVID patient contact without PPE

High Risk COVID patient contact without PPE

Low Risk COVID patient contact (was wearing PPE)

International Travel

Domestic Travel

Low clinical risk symptoms (Sore Throat, GI upset)

This patient has been determined to be {DESC; LOW/MEDIUM/HIGH:26590} risk for COVID-19

This patient {HAS HAS NOT:18834} been tested for Coronavirus (SARS CoV-2)

Date and Method of Testing (if applicable): ***

Given the LOW risk for Mortality and Morbidity this patient has been instructed to

Instructions: Smartlist: Choose Multiple

Return home and Self Isolate for *** days

Continue to adhere to CDC recommended Social Distancing; do not gather in crowded places, stay home when able, practice strict hand washing and minimize droplet spread at all times

Return to ER for worsening symptoms

Additional instructions include: ***

They clearly verbalized understanding of the following:

• They may spread the virus to others through droplet spread/close contact

• They must be available by phone at this number: @PHONE@ or alternative number: *** to be informed of test results.

• They must return to the ER for worsening symptoms of: Fever, Cough, Dyspnea.

Pertinent COVID Testing:

CXR/CT findings: ***

Inflammatory Markers

@RESUFAST(DDIMER,FERRITIN)@

@CRP@

CBC and LFTs

@LABRCNTIP(wbc:3,hgb:3,LYMPHOPCT:3)@

Does the patient have leukopenia? {YES NO:20877}

@LABRCNTIP(alkphos:3,bilitot:3,bilidir:3,prot:3,labalbu:3,alt:3,ast:3)@

@LABRCNTIP(aptt:3,inr:3,ptt:3)@

COVID – TREATMENT DOT PHRASE

This patient has Confirmed/High Suspicion for COVID-19

The medical team has discussed the following with the patient or their medical decision maker:

• COVID-19 is a novel disease as a result of Coronavirus (SARS CoV-2) and is highly contagious. Medical teams have been encouraged by CDC to modify best practices to minimize risk to staff while achieving best patient outcomes possible. This includes use of PPE, minimizing routine non-essential patient care, etc.

• The disease has significant risks of Respiratory Failure, Cardiac Arrest and Death

• All current treatments are based on observational study and consensus best practice

• The risks and benefits of current COVID treatments are not yet fully understood.

The patient’s Code Status is: @CODESTATUS@

The patient is being provided with the following COVID investigational treatments:

Treatments: Smartlist: choose multiple

Chloroquine/Hydroxychloroquine: Dose 400 mg BID for 2 doses, then 200 mg BID for 8 doses. (Can be PO or IV)

Azithromycin: Dose 500 mg Daily for 5 days

Remdesivir: Dose ***

Tocilizumab: Dose ***

Other Antiviral medication(s): ***

ARDS supportive measures + Mechanical Ventilation

ARDS supportive measures + Mechanical Ventilation with Proning

Pressor Support: ***

Diuresis with: ***