Introduction

Patient Selection

Patients included

This audit looks at all patients for particular keywords.  If a patient’s notes contain the keyword in question, then the patient is included in that cohort.

Business rules

Keywords

“Abuse”-”Awaiting Med”

1. Abuse

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “abuse” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: (may be slight variations of) tobbacco abuse, alcohol abuse, alcoholic abuse, opioid abuse, abuse-deterrent, denies abuse, etoh, polysubstance abuse, substance abuse, ABUSE (may be a comma after) IN REMISSION, abuse (may be a comma after) in remission, history of abuse, hx of abuse, every shift for behaviors, abuse uncomplicated, substance abuse, any drug abuse, drug abuse, alcohol abuse, domestic abuse of adult, cocaine abuse, monitor behaviors abuse, alcohol use disorder (may be a comma after) mild (may be a comma after abuse, narcotic abuse, heroin abuse, drug abuse, ETOH abuse, opiate abuse, nicotine abuse, opiod abuse, ethanol abuse, alc abuse, tobacco abuse, encounter, GERIPSYCH, t committee, abusive toward staff, abuse staff, care conference, PSYCHIATRY NOTE GENERAL, GENERAL INFORMATION, new admission

2. Abrasion

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the following words or phrases are found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: no abrasion, IDT review, daily wound assessment, no s/s of infection observed abrasions, HPI

3. Accuse

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “accuse” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: every shift for behaviors, potential for accusations, false accusation, no behaviors or accusations, no accusations, behavior monitoring, makes accusations, accusatory behaviors, get accusatory, no accusations

      3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

4. Aggressive

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “aggress” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria:behavior monitoring, has occasional episodes of, WEIGHT WARNING, CIC Evaluation, may be aggressive, IDT Review, CP meeting, therapy aggressive, A/P: Aggressive behavior, aggressive treatment, no aggressive/aggression, DISCHARGE SUMMARY, target behavior, for aggressive behavior, no aggression noted, Primary Language:, GERI-PSYCH, Review of Care Plan, aggressive control/pulmonary/management, aggressiveness of care, needs aggressive, for dementia with aggression, Care conference occurred this date, no unusual behavior or aggression, ry shift for behaviors, for agitation and aggression, for anxiety and aggression, less aggressi, history and physical, not aggressive, quarterly note:, care plan conference, for agitation/aggression, if pt/patient/resident becomes aggressive/aggression

      3. Note: if the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

5. Agitated

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “agitat” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: ANTIANXIETY/ANTIDEPRESSANT/ANTIPSYCHOTIC/MOOD STABILIZER side effect monitoring, any medication orders for agitat/anxiety, if pt/patient/resident becomes agitat, no agitat, ry shift for behaviors, 7=Anxiety/Agitation, quarterly/monthly MDS/review, for agitat

      3. Note: If the keyword is found in GEHRIMED or HPI Documentation, then it is excluded from the criteria.

6. Alcohol

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “alcohol” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: no known/history alcohol, no alcohol abuse, alcohol nasal swab, deny/denies/denied alcohol, alcohol solution

      3. Note: If the keyword is found in GEHRIMED or HPI Documentation, then it is excluded from the criteria.

7. Alleged

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “alleg” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: allegra

      3. Note: If the keyword is found in GEHRIMED or HPI Documentation, then it is excluded from the criteria.

8. Allergy/Allergic

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “allerg” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: any medication orders for allerg/pruritus, benadryl, nkda, allergy history, mucinex 

      3. Note: If the keyword is found in GEHRIMED or HPI Documentation, then it is excluded from the criteria.

9. Altercation

   1. Location in PCC:

      1. Progress Notes

   2. Business Rule:

      1. If the word “altercation” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

      2. Note: The following words and phrases are excluded from this keyword criteria: no altercation, prevent altercation, any number of days psycho-social evaluation

      3. Note: If the keyword is found in GEHRIMED or HPI Documentation, then it is excluded from the criteria.

10. Angry

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “angry” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: ry shift for behaviors, quarterly/monthly MDS/review, any digit angry, HPI, GEHRIMED

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

11. Argument

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “argument” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: annual/quarterly/monthly MDS/review/assessment, any digit and then argument

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

12. Aspirate

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “aspirit” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no aspirat, monitor for aspirat, placement of tube by aspiration, enteral feed order

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

13. Assault

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “assault” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: history of h\o assault, past\remote\history assault

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

14. Awaiting Med

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “awaiting med” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

“Bang” - “Burn”

15. Bang

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “bang” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: Bangura, observed lying on floor, fall, fell out of

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

16. Bleeding

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “bleeding” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: without bleed, no bleed, monitored\monitoring for bleed, report any unusual bleed, observed for s\s of bleed

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

17. Blister

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “blister” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: NEW AREA: No

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

18. Breast

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “breast” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication orders for rash\fungal\yeast\redness\wound, breastbone, daily wound assessment, bilat\B\L\bil breast, NEW AREA: No, under breast, breast remov\reduc, mastectomy, breast CA\cancer, wound breast, breast clinic, tattoo

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

19. Bruise

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “bruise” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: daily wound assessment, no bruise, NEW AREA: No

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

20. Burn

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “burn” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: heart burn, any medication orders for burn/pain, every shift for burn, deny/denies/denied burn

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Change in Condition” - “Cut”

21. Change in Condition

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “change in condition” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: call change in condition, monitor/monitored change in condition, if any other sx or change in condition, s/p change in condition, no change/changes in condition, does not reflect a change in condition, change in condition documented in error, wrong documentation, change in condition d/t, MEETING ATTENDANCE:, no change noted, change in condition has been completed, no acute change in condition, next update or change in condition, no apparent change in condition, complete a change in condition if needed, if change in condition, complete a change in condition

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

22. Choke

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “chok” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: Two kinds of choking: clinical and behavioral

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

23. Combat

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “combat” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: Target behavior: Combatative, No combat

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

24. Congest

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “congest”  in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for congest, suction PRN, COVID Screener, no congest, Robitussin, screen for COVID/Covid

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

25. Cough

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “cough” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for cough/expectorant, screen for COVID/Covid, COVID Screener, no cough, Cough/Cold Oral Tablet

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

26. COVID

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “covid” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: negative, screen for COVID/Covid, COVID Screener, COVID-19 Symptoms Evaluation, decline covid test, any medication order for covid/COVID

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

27. Cry/Crying

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “cry” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any number = cry, every shift for behaviors, annual/quarterly/monthly MDS/review/assessment, any number and then crying

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

28. Curse

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “curse” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: every shift, excursion, Quarterly Assessment, Monthly Behavior note

       3. Note: If the keyword is found in HPI Documentation then it is excluded from the criteria.

29. Cut

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “cut” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: cut higher dose, NEW AREA: No, cut short his dialysis/some calories/into small pieces/it into 4/xeroform/from insurance/strips of occlusive, Cutright, cutibacterium, cutting food

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Decline” - “Dyspnea”

30. Decline

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “decline” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: decline is not noted, decline appointment/weight being obtained/medication/dose/labs

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

31. Demand

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “demand” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: req on/per demand, postpone only until demand

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

32. Depressed

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “depressed/depression” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for depress, deny/denies/denied depress

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

33. Diarrhea

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “diarrhea” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: screen for COVID/Covid, COVID Screener, any medication order for diarrhea, miralax, deny/denies/denied diarrhea, no  diarrhea, Anti-Diarrheal Oral Tablet, side effect monitoring

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

34. Difficulty of breathing/DOB

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “difficulty breathing” or its acronym “dob” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: pseudobulbar, PSEUDOBULBAR, Raymond dob, morbidobese, DOB with any date value, correct DOB/dob, name, DOB

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

35. Dislocation

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “disloc” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: negative findings for dislocat

36. Discoloration

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “discolor” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no discolor, No new obvious deformities/discolorations

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

37. DTI

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “deep tissue injury” or its acronym “dti” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: NEW AREA: No, daily wound assessment, every shift for DTI

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

38. Dysphagia

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “dysphagia”in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

39. Dyspnea

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “dyspnea” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for dyspnea, no dyspnea

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Ecchymosis” - “Expose”

40. Ecchymosis

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “ecchymosis” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no ecchymosis

41. Edema

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “edema” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for edema, no edema, (annual/quarterly/monthly) (MDS/review/assessment), every shift for edema, (deny/denies/denied) edema, free of edema

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

42. Elevated Temperature

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “elevated temperature” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: acetaminophen

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

43. Elevator

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “elevator” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria:

       3. Note: If the keyword is found in HPI Documentation then it is excluded from the criteria.

44. Elope

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “elop” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: annual/quarterly/monthly MDS/review/assessment, history/hx/risk/possible/prevent elope/elop risk, discontinue/prevent/precaution, any number and then elope, no elope

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

45. Emesis

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “emesis” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no emesis, Ondansetron, Zofran

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

46. Excoriation

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “excoriation ”in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for excoriation, every shift for excoriation, excoriation ... to ... has resolved

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

47. Exit

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “exit” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no exit, annual/quarterly/monthly MDS/review/assessment/progress note, they exit/exited/exting/exits the room/building, any number and then exit, does exit seek, at time of exit, IDT, PAS exited with resident, every shift for exit-seeking/behaviors

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

48. Expose

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “expos” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: apply to exposed skin, exposed bone, bone exposed/exposing/expose/exposure, pressure ulcer/wound/injury, COVID, covid, exposed/exposing/expose/exposure hardware, s/s of respiratory, fat layer exposed, exposed/exposing/expose/exposure catheter, catheter exposed/exposing/expose/exposure, exposed/exposing/expose screw, exposed/exposing/expose/exposure smoke, lungs clear, Agent Orange exposed/exposing/expose/exposure, mesh exposed/exposing/expose/exposure, exposed/exposing/expose/exposure keratopathy, exposed/exposing/expose/exposure substance/radiation/air/ATB, tobacco/disease/needle/automate/dog/isolat/smok/tendon/ATB exposed/exposing/expose/exposure, exposure

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Faint” - “Found”

49. Faint

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “faint” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria:  faint rhonchi/wheeze

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

50. Fall

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “fall/fell” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: fall asleep, every shift for fall, fall precautions maintained, NEW AREA: No, no fall, deny/denies/denied fall, Mc Fall

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

51. Fever

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “fever” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for pain/fever, deny/denies/denied fever, no fever, fever free, Side effect monitoring

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

52. Fight

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “fight” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: firefight, fight infection, no fight

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

53. Floor

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:    

       1. If the word “floor” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: WEIGHT WARNING, floor pantry/divider/nurse, hitting head on the floor to pray

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

54. Fracture

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “fracture” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any of the following: fracture, no fracture, every for fracture, any medication for pain, History of Present Illness, history/hx of fracture, assessment plan fracture

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

55. Found

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “found” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: found none, no found, found to elevated/letharg/capacity, found on/in the chart

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Grabbed” - “Ground”

56. Grabbed

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “grabbed” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: grab gna/cna/nurse/LPN

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

57. Groped

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “groped” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

58. Ground

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “ground” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: coffee ground/grounds, ground meat/food, feet/foot flat on the ground, ground texture diet, meat/food ground

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Headache” - “Hypoxia”

59. Headache

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “headache” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: ANTIANXIETY/ANTIDEPRESSANT/ANTIPSYCHOTIC/MOOD STABILIZER side effect monitoring, Respiratory/COVID/Covid screener, any medication order for headache/pain/migraine/anxiety, 2=headache, Screen for S/Sx of COVID-19, no/deny/denies/denied headache, every shift for screener/booster

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

60. Hematoma

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “hematoma” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no hematoma

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

61. Hit

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “hit” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: did not/Deny/denies/denied hit head, Darlene Hitt, HPI, GEHRIMED, no hit, Maryella Hitt, every shift for behavior, observed lying on floor, fall, fell out of, hit gna/cna/nurse, hit h table/desk/floor/door

62. Homicidal

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “homicidal” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: did not/deny/denies/denied homicidal, no homicidal, homicidal none

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

63. Hypersexually

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “hypersecually/sexual advances/increased sexual activity” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: If the keyword is found in GEHRIMED Documentation then it is excluded from the criteria.

64. Hypoxia

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “hypoxia” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: every shift for hypoxia

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Ingest” - “Intercourse”

65. Ingest

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “ingest” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for ingest/indigest, HPI, GEHRIMED, meetingestimate

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

66. Injury

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “injur” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: with out/without/w/o injur, no injur, (dti/DTI/Dti), deep tissue injur, denies/denied/deny injur, assessed for injur, avoid injur, every shift for injur, WEIGHT WARNING, attempt to prevent injur, no complaints of pain or discomfort injur, possibility of injur, did not have injur, mitigat injur

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

67. Intercourse

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “intercourse/inter course” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

“Kick” - “Knife”

68. Kick

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “kick” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: kick/kicks off, 8=kicking, kick in, kick gna/cna/nurse/GNA/CNA/LPN, kick out

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

69. Knife

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “knife” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: keller tool & knife sharpening

       3. Note: If the keyword is found in HPI Documentation then it is excluded from the criteria.

“Labored Breathing” - “Lymphedema”

70. Labored Breathing

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “labored breath” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no labored breath, any medication order for shortness of breath/sob/SOB/pain, un/nonlabored breath

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

71. Laceration

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “laceration” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for laceration, no laceration

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

72. Leave

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “leav” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: leave wound/OTA/open to air/the air, leave message/a message, leave in catheter, leave on at all times, leave voice mail/a voice mail/voicemail/a voicemail, leave resident on NC, leave me be, leave O2 in place, leave in place, leave on any number of hours/days, leaving for dialysis/bowls/for appointment/for apt/for a message), leave brief on, leave alone, leave me/him/her/them alone, leave the EBP/appointment, refuse/refused/refusal/refusing to leave, when he/I/she/they leave later/today, MDS/Assessment, annual|quarter/quarterly/month/monthly MDS/Assessment, leaves the bed, No acute distress noted upon/prior to/prior leaving, the team would leave, asked writer to leave, leaving foley in place, do not leave on

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

73. Lethargy/Lethargic

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “letharg” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no letharg, hold if/for patient/pt letharg, every any number of hours for lethargy, lethargic for any number of day/quarter/quarterly/QTY assessment/MDS

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

74. Lying

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “lying” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: Position: Lying, lying on side, lying comfortable/comfortably, lying flat/abed/position, lying on/in the/his/her bed/air mattress/floor/fall mat, lying on back, sit/sitting to lying, lying to sit/sitting, lying la, lying supine, lying left/right arm, left/right side lying, any number out of any number lying, lying any number out of any number

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

75. Lymphedema

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “lymphedema” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for lymphedema, quarterly/QTY review/MDS, every shift, any medication order for lymphedema, no lymphedema

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Mad” - “Medication not given”

76. Mad

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “mad” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

77. Malaise

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “malaise” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: Monitor COVID-19 post vaccination, denies/denied/deny malaise, no malaise

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

78. MASD

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “MASD” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for masd, masd to ... healed, healed masd, every shift for masd, PROGRESSION: Healed

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

79. Medication not administered

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “medication not administered” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

80. Medication not available

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “medication not available” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

81. Medication not given

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “medication not given” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

“Nausea” - “Neglect”

82. Nausea

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “nausea” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for nausea, no nausea, Diarrhea, Nausea/Vomiting, denies/denied/deny nausea, ANTIANXIETY/ANTIDEPRESSANT/ANTIPSYCHOTIC/MOOD STABILIZER side effect monitoring

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

83. Neglect

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “neglect” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: denies/denied/deny neglect, no neglect, hemineglect/hemi neglect, self neglect

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“On order” - “Outburst”

84. On order

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “on order” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: Dental referral

85. Open area

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “open area” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no open area, any medication order for open area, clean/cleanse open area, any medication order for wound open area, quarterly review/MDS, denies/denied/deny open area, every shift for open area

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

86. Outburst

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “outburst” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no outburst, denies/denied/deny outburst, quarterly review/MDS

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Pain” - “Push”

87. Pain

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “pain” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for pain, denies/denied/deny pain, no pain, pain = 0, every shift, The Change In Condition/s reported on this CIC Evaluation are

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

88. Penis

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “penis” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: apply to penis, daily wound assessment, cath, of penis, to penis

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

89. Police

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “police” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

90. Pull

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “pull” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: pull call-light/call light, no pull, pull sleeve, 4t pulling privacy curtains down

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

91. Punch

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “punch” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: punch code

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

92. Push

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “push” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: push fluids/H2O, push call-light, call light, push off

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Rales” - “Rough”

93. Rales

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “rales” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no rales, without rales

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

94. Rash

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “rash” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for rash, every shift/morning/evening for rash, Rashid, ANTIANXIETY/ANTIDEPRESSANT/ANTIPSYCHOTIC/MOOD STABILIZER side effect monitoring, no rash

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

95. Redirect

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “redirect” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: Acetaminophen/Ativan/Tylenol/ALPRAZolam/LORazepam/Percocet tablet/oral tablet, Morphine Sulfate, oxyCODONE/Cyclobenzaprine/traMADol/Ativan/HYDROmorphone/Promethazine HCl tablet/oral Tablet/Capsule/oral capsule, any number and then redirect, any number and then attempt to redirect, 2=Agitation

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

96. Redness

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “redness” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no redness, any medication order for redness, looking at the skin for any redness, check for redness, check redness, without redness

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

97. Refuse/Refusal

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “refus” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: 7t Refused/Declined

       3. Note: If the keyword is found in GEHRIMED Documentation then it is excluded from the criteria.

98. Rhonchi

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “rhonchi” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: no rhonchi

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

99. Rough

    1. Location in PCC:

       1. Progress Notes

    2. Business Rule:

       1. If the word “rough” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

       2. Note: The following words and phrases are excluded from this keyword criteria: roughly any number and then month/day/week/suture/ml/mg/kcal/places, rought, rough day/night, roughly, roughing any number-any number, search rough, roughly any percentage

       3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Scratch” - “Swell/Swollen”

100. Scratch

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “scratch” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: every shift for scratches/treatment, itch, 10=Scratching, scratchy throat, no scratch, scratch stick

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

101. Scream

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “scream” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: no scream

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

102. Shear

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “shear” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: Shearon, Shearer, CVSheart

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

103. Shortness of breath/SOB

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “shortness of breath/sob/SOB” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for shortness of breath/sob/SOB, every shift for COVID/Covid/covid/covid-19 screener, no shortness of breath/sob/SOB, quarter/quarterly/annual/month/monthly note/assessment/MDS, denies/denied shortness of breath/sob/SOB, every shift for shortness of breath/sob/SOB, zero shortness of breath/sob/SOB

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

104. Shout

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “shout” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: washout

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

105. Skin tear

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “skin” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

106. Slam

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “slam” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: Slampack

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

107. Slap

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “slap” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: 11=Slapping, quarter/quarterly/annual/month/monthly note/assessment, quarterly MDS/review

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

108. Slid

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “slid” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

109. Slip

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “slip” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: diet/LOA/lab/pink slip, non slip, slipper

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

110. Smoke/Smoking

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “smok” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: for smoking cessation, no smoke/smoked/smoker/smoking/smokes/smokers, current/former smoker, (quarter/quarterly/annual/month/monthly note/assessment, smoking area/porch, is a smoker, safe smoking, smoking acknowledgement, smoking copy, smoke break, side effects of smoking, smoker

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

111. Spit

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “spit” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: rinse/rinse mouth/swish and/then spit, no spit

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

112. Strike

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “strike” or “struck” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: strike out, denies strike, did not strike, strikethrough, no head strike

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

113. Stumble

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “stumble” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

114. Suicidal

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “suicid” or “kill self/selv” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: did not/deny/denies/denied suicid, no suicid, suicid none, ANTIDEPRESSANT side effect monitoring

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

115. Swallow

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “swallow” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: GI issues/swallowing difficulties/nutritional disorder, no swallow/swallowing, denies/denied swallow/swallowing, swish and/& swallow, free of swallowing issues

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

116. Swear

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “swear” or “swore” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: Swearingin/swearingen/swearengin/swearengen, I swear

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

117. Swell/Swollen

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “swell” or “swoll” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: no swell/swelling/swollen, denies/denied swell/swelling/swollen, swelling at the injection site, any medication order for swell/swelling/swollen, monitor/monitored/moniter/monitered/monitoring/monitering/notify for swell/swelling/swollen, or if have increased swelling or SOB

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Tearful” - “Touch”

118. Tearful

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “tearful” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for tearful, target behavior tearful, any number and then tearful, annual/quarterly/monthly MDS/review/assessment/progress note, no/not tearful, denies/denied tearful

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

119. Threat

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “threat” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: No threat

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

120. Threw up

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “threw up” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: threw/throw up hands, No/no/NO threw/throw/throwing/thrown up

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

121. Throw

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “threw” or “throw” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: threw/throw/throwing/thrown up, threw/throw/throwing/thrown away, threw/throw/throwing/thrown in the garbage/trash, 12=Throwing objects

122. Touch

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “touch” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: flextouch, (warmer/warmth/cold/colder/painful/tender/W/d/W/D/w/d/dry/moist/sensitive/cool/soft) to the touch, be/stay/get in touch, light/gentle touch, touch base, Sensory Visit, Bosutinib

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Ulcer” - “Upset”

123. Ulcer

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “ulcer” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: any medication order for ulcer, daily wound assessment

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

124. Unresponsive/Non Responsive

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “unresponsive” or “nonresponsive” or “non responsive” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

125. Unstageable

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “unstageable” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

126. Upset

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “upset” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: upset GI/stomach, GI/stomach upset, mylanta, quarterly assessment, chews objects when upset

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Vagina” - “Vulgar”

127. Vagina

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “vagina” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: estrogens conjugated vaginal cream, monistat, estradiol/estrace/Clotrimazole-Betamethasone/Premarin/Fluconazole/Miconazole Nitrate/Diflucan Oral/medroxyPROGESTERone Acetate Oral/Megestrol Acetate Oral vaginal cream/tablet, no vagina, Betadine Swabsticks External Swab, uti, UTI, yeast

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

128. Violation

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “violat” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

129. Vomit

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “vomit” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: denies/denied vomited/vomiting, no vomited/vomiting, any medication order for vomited/vomiting, every shift for COVID/COVID-19 screener

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

130. Vulgar

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “vulgar” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: Vulgaris

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Wander” - “Wound”

131. Wander

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “wander” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: wander guard/wanderguard, quarterly/annual update/updates/MDS/care plan review, 13=Wandering, Social Services Annual/Admission, restlessness/vertigo/wandering/ecchymosis

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

132. Weapon

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “weapon” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

133. Weight Loss

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “weight loss” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: ensure, super donut, house shake/pudding/supplement, medpass/med pass product, MIGHTY SHAKES, weights monthly, Mirtazapine Tablet, every shift, two/2 cal, fortified pudding

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

134. Wheeze/Wheezing

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “wheez” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: as needed for wheezing, wheeze/wheezing is/has/much improved/improving, no wheezing/wheezes/wheeze, any medication order for wheezing/WHEEZING/wheeze, denies/denied wheezing/wheezes/wheeze, without wheeze/wheezing/wheezes, palpitations Respiratory: shortness of breath/wheezing, negative wheezing/wheezes/wheeze, not present: wheezing/wheezes/wheeze

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

135. Worsening

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “worsening” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: did/does not show any worsening, no new or worsening symptoms, monitor/monitored/monitoring/notify for worsening, no worsening, is/has not worsening, prevent worsening

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

136. Wound

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “wound” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: GENERAL INFORMATION, wound care, to eval and treat if indicated, enhanced barrier, wound drsgs c, to aid in wound healing, for wound care, Treatment order, cleanse wound cleanser, daily wound assessment, NEW AREA no, Wound Tx, no wound, by wound nurse, cleanse, pack, cover, initial skin assessment, Skilled Service, wound rounds, wound clinic, dry crust over most of wounds, no known wounds, with wound cleanser, SECONDARY, for wound, wound dressing, weekly skin check, wound healing, for wound, wound CNP, wound team, New admission, Care plan reviewed and is appropriate, wound consult, refused wound, IDT NOTE, seen by wound nurse, wound nurse practitioner in, continue wound care, WOUND:, TX:, wound nurse in, wound nurse already, for wound, clean with NS, due to wound, presented with wound, for wound healing, weight, admitted to facility, resident arrived, vacs, vac, document abnormalities, bleeding from wound, for skin tear, in her/his wound, clns wound, H and P, no skin tear, new admi, BMI, dress wound, wund foam, wound monitor, apply to wound, wound on intact, surgical wound, wound tx, wound draining, wound pain, wound infection, Weekly assessment, sent to wound nurse, upon admission, tearful, r/t wound, prior wound treatment, apply dry dressing, admission skin check, wound closed, refus wound , WOUND INFECTION, wound infection, seen by wound nurse, apply wound, previous wound, resolved, skin assessment completed, promote healing to wounds, tx in place, to wound, to skin tear, skin tear remains, wound remains, wound culture, Medi-honey, wound healed, wound wash, Date of service: , skin tear healed, clns skin tear/s/t, wound order, wound note, wound center, regarding the patients wounds, worsening wound, requested wound NP, family wound like, wound md in/exami/assess, wound NP in/exami/assess, MDS Addendum, r/t wound infection, site healing, wound like, MDS Addendum, ABT r wound, ulcer improve, no open areas noted to skin, wound rounds completed, wounds with good granulation., no areas noted to skin, wound remained stable, wound/wounds rounds completed No new orders at this time, No treatment needed, no skin areas noted at this time, no impairment to skin integrity, wound healing/improving, HD RD update:, wound cx, Monitor Wound VAC, Wound Vac continuous at, for dressing changes, FOLLOW-UP EVALUATION, area is improving, continue with treatment, via stretcher, wound CNP/NP in to/into/to see, seen by wound NP, Other concerns:, no change in redness, Wound Nurse assessed, IDT, for previous skin tear/wound, Dressing Dry and Intact:, wound nurse spoke, orders received from wound, dressing dryand intact, wound treatment done, NEW AREA: No, assessed resident for skin tears, to protect from skin tears, wound vac setting is, declin wound assessment/treatment, wounds assessed during rounds, getting his/her wound checked, Improper positioning in bed or w, wound round completed, ID Team, seen by wound np, seen by wound dr, at wound appointment, pressure ulcer is stable, PUI/PU healed, wound clean, readmitted, UR meeting, wound cont. to be monitored, assisted with wound rounding, loss over 30 days, from wound drain, wound nurse completed, CRNP wound

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.

“Yell” - “Yell”

137. Yell

     1. Location in PCC:

        1. Progress Notes

     2. Business Rule:

        1. If the word “yell” in any form is found in the Progress Notes, then Yes.  Otherwise, No.

        2. Note: The following words and phrases are excluded from this keyword criteria: yellow/yellow, every shift, Yellinedi, not yell, monthly behavior/behavioral note, quarterly review, donyelle, no yell, for any number of days yelling

        3. Note: If the keyword is found in GEHRIMED or HPI Documentation then it is excluded from the criteria.