Md smart tool
Lungs – clear to auscultation, no accessory muscle useĬOR – RRR without S3/S4/M, no carotid bruits (Incidentally for the most part I try not to abbreviate creating SmartPhrases since it doesn’t save any time and I don’t want other readers to have guess what it means, but I keep some that are pretty ingrained in clinicians and are unlikely to be confused).Ībd – soft, nontender without mass or hepatosplenomegaly HEENT – PERRLA, EOM with FROM, normal conjunctiva & lids, throat clear, normal lips, gums and teeth, neck symmetric without cervical or supraclavicular adenopathy or mass, thyroid normal
General – Patient appears well in no apparent distress, alert & oriented. ha = headache.įor the physical exam in Objective, each system as a Smart Phrase, for example: When recording the history, if you’re not using Dragon, use SmartPhrases for common things to save time, such as. I also use the Synonyms tab to add other names, especially for ones I have problems remembering. I try to be consistent with how I name SmartPhrases to make them easier to remember. (the latter created with the SmartPhrase. I just add the date and make reference such as:Ħ/12/14 Lab – See report. I then check to see what tests the patient has had, and what specialists the patients has seen, and add those at the bottom of the Objective section. I use the following SmartLinks all the time in SmartPhrases: after typing or using Dragon, the sentence now looks something like, “At his last visit I started him on lisinopril.” ALV (At last visit I) and then add what I did. At the end of first sentence I type the SmartPhrase. The patient’s relevant past medical, surgical and social history was reviewed in Epic.Ģ)Hyperlipidemia – At NCEP ATP III guidelines.ģ)Type 2 Diabetes Mellitus – Uncertain control.īefore pasting and still looking at the last note, I also check the plan and often add what I did then to my current note. Now my note my look something like:ħ2 year old male with complaints/comments per nursing/medical assistant note, with all such history reviewed for accuracy and confirmed by myself. I then look at my last note (often using a Dragon script to get it quickly) and copy and paste my assessment. I usually enter this in my office, reviewing the chart before I go in to see the patient. To use a SmartPhrase within a SmartPhrase you just precede and end it with The final SmartPhrase MEF is just one I created to add the FACP title, which the built in.
The patient’s relevant past medical, surgical and social history was reviewed in the SOAP elements visually makes it easier to find things. soap which looks like with complaints/comments per nursing/medical assistant note, with all such history reviewed for accuracy and confirmed by myself. If acting as a specialist and doing a consultation I might do the same.) Unless I’m doing a physical, which has its own scripts, my baseline script is. as the information is already in Epic and it just clutters up the note (I do bring in much of the information for physicals because I think that’s the one time it’s useful to have everything in one note. I also don’t like to pull in information into my note, such as past history, labs, etc. My approach is to be modular in creating SmartPhrases, as I’ll demonstrate below. These are text, ranging from one word, to multiple pages of material, generated by typing the name of the SmartPhrase, preceded by a period. In this post I’ll explain how I use SmartPhrases. I previously wrote that I have done a lot of customizations to Epic. If you do not use the electronic medical record Epic Hyperspace, this article is probably of no interest to you.