Macros

Macros are a fast consistent way to add information to a template. Typing the shortcut will expand to the text that corresponds to it. The parts of the boilerplate text that may need to be edited appears in brackets. Note to keep the naming of the macros different from nonmacro text they often will begin with a period (.).

Purpose Shortcut Text
Two midnight boilerplate text for admission 2mn The patient is expected to need 2 midnights of inpatient care for the management of (add diagnosis) that is complicated by (add co-morbidities), and who has a significant risk of (add complications) if not hospitalized.
Two midnight boilerplate text for discharge prior to two midnights 2mndc The patient’s (add S & S or Diagnosis) improved after (add outline of treatment) in less than 2 midnights. Therefore, the patient is being discharged (add date) to (add destination) to follow up with Dr. (add physician) in (add # days) days.
Progress notes .pnote cc:

Int Hx:

PE:
VS reviewed
Gen: nad
Resp: ctab
cv: s1 s2
abd: soft nt nd bs+
Psych:

Labs and studies:
Pertinent labs:

Radiology:
Personally reviewed:

ecg/tele:
Personally reviewed:

Other studies:

A/P:

Congestive heart failure .chf This patient has (acute, chronic, acute on chronic) (systolic, diastolic, combined systolic and diastolic) congestive heart failure.
COPD .copd This patient has (Acute exacerbation / Acute on chronic /Chronic-stable) COPD. This patient (is / is not) home oxygen dependent . The patient uses Tobacco (currently / history of). Related conditions include (chronic respiratory failure/ acute respiratory failure / acute on chronic respiratory failure / acidosis/ alkalosis). The (patient does / does not have) Hemoptysis. This patient (does / does not) have related (mild /moderate / severe) (protein-calorie / other) malnutrition as evidenced by (clinical indicators-BMI / albumin / muscle wasting /cachexia). This patient will be treated with (oxygen and saturation monitoring /IV steroids / nebulizer treatments /inhalers /etc.).