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]