General Documentation
Patient Data
.NAME .DOB .AGE .SEX .VS
.ORTHO Extended VS .BMI .PCP .PMH .PSH .FAMHX .SOCHX .TOBHX
Dates
.TODAYDATE or .TD - Today’s date-will refresh
.TDNOREFRESH Today’s date-will not refresh
.ENCDATE Date of encounter
Your Signature
.ME Name and degree
.SIGNME Name, Title, Date & Time
You can also create your own custom signature and save it. To do this, go to your Smart phrase Manager, create a new Smart Phrase, name it, and then fill in your desired fields (e.g. Full Name, MD/DO, Family Medicine PGY-X, Pager #, current date and time).
Scoring Tools
.DEPRESSIONASSESSX3 Last 3 PHQ’s
.ANXIETYASSESSX3 Last 3 GAD’s
.ASCVD - Framingham risk score
Health Maintenance and Screening
.HMDUE OVERDUE health maintenance
.HMLIST ALL health maintenance
.DIABETESREGISTRY
All diabetes measures and dates satisfied
Diagnoses and Problem List
.ASSESSPLAN2 Dx’s, orders and other orders.
.DIAGMED Dx’s, orders & *** (not refreshable)
.DIAGMEDREF Dx’s, orders & *** (refreshable)
.DIAGNOORDERS Dx’s (no orders) & ***
.PROBLCOMMENTS Entire PL with Overview Notes
.PROBDIAGCOMMENTS
Medications
.CMED2 Final med list in grid format (#,dose)
.CMEDNAME Final med list in prose format
.MEDSDISCONTINUED Meds D/C’d
Labs
.A1C .A1CLAST3
.BMP .TSH
.LIPIDS .LASTCBC
.NUCRESTEXT Lab/procedure results this visit
.THISVISIT Labs/POCT performed this visit
.GETLABS[1m,2
Brings in all labs within previous period of time (i.e. 1m=1 month; 1w=1 week) Digit after comma determines format [0/blank = long; 1=shorter; 2=short]