Text Macros for FM

[June11]

Just completed my first year as a working PA in family medicine and am feeling a bit burned out. I work in an older, less educated community and there’s a lot of disease. We see 20 patients a day but luckily have scribes. Unfortunately, the scribes often are new without much medical knowledge so I’m having to change my charts often. I would very much appreciate some text macros that you use most in your practice so I can cut down on charting time. Thank you!!

[ventana]

I have yet to get any.... so posting the ones I have recreated so far....

 

Colo CA Screening

Discussed the three options of colon cancer screening, stool cards, cologuard, colonoscopy and negatives and positive of all three. With shared decision making we choose ____________.

 

exercise

 

It’s about getting the body moving!

Get 150 minutes of moderate activity

With obesity, increase minutes - 300 minutes per week

Find your soulmate workout

Include weight training

It helps maintain your weight

Build purposeful activity at home

Start your day with exercise

Try to take 10,000 steps a day

 

Script monitoring program search 

The MassPat database was quired and reviewed before script was provided. Discussion about the specific medication being written was had with the patient and any caregivers present. This included risk of dependency, sedation, drug-drug interaction, the requirement to keep controlled substances secure and not sharing. Patient instructed to use the minimal amount of controlled medication needed and to not combine with other medications.

 

Mediterranean Diet

The traditional Mediterranean diet is based on foods available in countries that border the Mediterranean Sea. The foundation for this healthy diet includes:

~~an abundance of plant foods, including fruits, vegetables, whole grains, nuts and legumes, which are minimally processed, seasonally fresh, and grown locally

~~olive oil as the principal source of fat

~~cheese and yogurt, consumed daily in low to moderate amounts

fish and poultry, consumed in low to moderate amounts a few times a week

~~red meat, consumed infrequently and in small amounts

~~fresh fruit for dessert, with sweets containing added sugars or honey eaten only a few times each week

~~wine consumed in low to moderate amounts, usually with meals.



Specific Ideas to try

~Switch from whatever fats you use now to extra virgin olive oil.

~Eat nuts and olives.

~Add whole-grain bread or other whole grains to the meal.

~Begin or end each meal with a salad.

~Add more and different vegetables to the menu.

~Eat at least three servings a week of legumes.

~Eat less meat.

~If you have no problems with alcohol - substitute wine in moderation for other alcoholic beverages.

~Cut out sugary beverages.

~Eat less high-fat, high-sugar desserts.

~Seek out the best quality food available.

 

PE Exam

PHYSICAL EXAM

General: Awake, alert, and oriented. No acute distress, well developed and nourished. Appears stated age.

Skim Skin is warm dry, intact without rashes or lesions. Nail beds pink without cyanosis or clubbing

Head: The head is normocephalic and atraumatic.

Eyes: Conjunctivae are clear without exudates or hemorrhage, Sclera is nonicteric. EOMI intact, PERRLA No signs of nystagmus. Eyelids are normal in appearance without swelling or lesions.

Ears: The external ears and canals are non-tender and without swelling. The canals are clear, TMs are normal in appearance with normal landmarks and light reflex.

Nose: Nasal mucosa is pink and moist. The nasal septum is midline. Nares are patent bilaterally.

Throat; Nasal mucosa is pink and mist with good dentition. Tongue normal in appearance without lesions and mth good symmetrical movement, No buccal nodules or lesions are noted.

Pharynx is normal in appearance without tonsillar swelling or exudates.

Neck: The neck is supple without adenopathy, Trachea is midline. Thyroid gland is normal Without masses.

Cardiac RRR. No murmurs, rubs, gallops. Normal S1, S2.

Respiratory: Chest wall symmetric without deformity. Lung sounds clear in All fields bilaterally without rales, rhonchi, or wheezes,

Abdomen: Soft, symmetric, non-tender without distention, Bowel sounds are present and normoactive in all four quadrants. No masses, hepatomegaly, or splenomegaly are noted.

Musculoskeletal: Upper and lower extremities are atraumatic in appearance without tenderness or deformity.

Cap refill seconds.

Steady gait noted.

Neurological: Alert, awake, oriented to person, place, time with normal speech.

Psychiatric: Appropriate mood,

 

 

PRE-OP

Patient was seen for pre-operative evaluation



Is __________ reasonable to proceed forward with surgery as scheduled





Is able to ambulate at least 4mph flat level ground and climb stairs with out issues

No History of problems with anesthesia

No dentures, partials or removable teeth

No Neck Issues

No Excessive Alcohol or other substance use to be overly concerned with



MEDICATION directions

Stop _____________ days before

Stop _____________ days before

Stop _____________ days before



Please keep appointment with Anesthesia for evaluation as well

 

 

 

Time of Visit 

Time spent in preparation, face to face and documentation was ______________ minutes . This time includes may preparing to see the patient, parentheses e.g. review of tests and specialist notes), obtaining and reviewing separately, obtained history, performing and medically appropriate examination and or evaluation, counseling, and educating the patient/family/caregiver, ordering medication, tests, or procedures, referring and communicating with other healthcare professionals, documenting clinical information in the medical record, independently, interpreting results, and communicating results and care coordination.



Please note this note is use to communicate complex medical issues and the use of abbreviations and medical terminology may be extensive. It is not intended for patient edcuation or counseling.

 

 

 

Home BP

Pateint was instructed on how to take home BP with and automatic machine.

---Be still. Discuss how to use your home blood pressure monitor with your health care professional. Don't smoke, drink caffeinated beverages or exercise within 30 minutes before measuring your blood pressure. Empty your bladder and ensure at least five minutes of quiet rest before measurements.

---Sit correctly. Sit with your back straight and supported (on a dining chair, rather than a sofa). Your feet should be flat on the floor and your legs should not be crossed. Your arm should be supported on a flat surface, such as a table, with the upper arm at heart level. Make sure the bottom of the cuff is placed directly above the bend of the elbow.

Check your monitor's instructions for an illustration or have your health care professional show you how.

---Measure at the same time every day. It’s important to take the readings at the same time each day, such as morning and evening. It is best to take the readings daily, ideally beginning two weeks after a change in treatment and during the week before your next appointment.

---Take multiple readings and record the results. Each time you measure, take two readings one minute apart and record the results. If your monitor has built-in memory to store your readings, take it with you to your appointments.

---Don't take the measurement over clothes.

 

 

 

PE Short

Alert Oriented x3 Moves about the exam room without difficulty Head Atraumatic Eyes PEARLA EOMI grossly intact Hearing grossly intact Cardiovascular Regular rate and rhythm no murmur rubs or gallops Respiratory Clear to Auscultation, no wheezes rales or rhonchi Abdomen Soft non tender to palpation, no appreciable organomegaly Extremities moves all extremities no edema