Hi all!
I'm attempting to create medical templates for my class and clinic team members. I've created 4 versions below for generalized abdominal pain below and am curious which you think would be the best/easiest to use for documentation. The goal is to implement a template format that is easiest and quickest to use/navigate for someone who has never seen them before
We have Cerner and the F3 function allows you to jump to the next underscore. Information in parenthesis would have to be deleted which I know can be a pain..
If none of these are good, I'd love alternative versions that you think would work better.
#1 BULLET BASIC PREFILL
Generalized Abdominal Pain
- Onset was _ ago
- Context: without known trigger_ triggered by _
- Symptoms described as _generalized abdominal pain
- Occurs _
- Severity is worsening_ improving_ unchanged
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: No _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea, nausea, vomiting)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
#2 BULLET EMPTY
Generalized Abdominal Pain
- Onset was _ ago
- Context: _
- Symptoms described as _ (generalized abdominal pain)
- Occurs _
- Severity is _
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: No _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea, nausea, vomiting)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
#3 LINEAR BASIC PREFILL
Generalized Abdominal Pain
- Onset was _ ago, without known trigger_ triggered by _
- Symptoms described as _generalized abdominal pain
- Occurs constantly_ intermittently and severity is worsening_ improving_ unchanged
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
#4 LINEAR EMPTY
Generalized Abdominal Pain
- Onset was _ ago, _
- Symptoms described as _ (generalized abdominal pain)
- Occurs _ and severity is _
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
I'm attempting to create medical templates for my class and clinic team members. I've created 4 versions below for generalized abdominal pain below and am curious which you think would be the best/easiest to use for documentation. The goal is to implement a template format that is easiest and quickest to use/navigate for someone who has never seen them before
We have Cerner and the F3 function allows you to jump to the next underscore. Information in parenthesis would have to be deleted which I know can be a pain..
If none of these are good, I'd love alternative versions that you think would work better.
#1 BULLET BASIC PREFILL
Generalized Abdominal Pain
- Onset was _ ago
- Context: without known trigger_ triggered by _
- Symptoms described as _generalized abdominal pain
- Occurs _
- Severity is worsening_ improving_ unchanged
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: No _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea, nausea, vomiting)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
#2 BULLET EMPTY
Generalized Abdominal Pain
- Onset was _ ago
- Context: _
- Symptoms described as _ (generalized abdominal pain)
- Occurs _
- Severity is _
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: No _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea, nausea, vomiting)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
#3 LINEAR BASIC PREFILL
Generalized Abdominal Pain
- Onset was _ ago, without known trigger_ triggered by _
- Symptoms described as _generalized abdominal pain
- Occurs constantly_ intermittently and severity is worsening_ improving_ unchanged
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
#4 LINEAR EMPTY
Generalized Abdominal Pain
- Onset was _ ago, _
- Symptoms described as _ (generalized abdominal pain)
- Occurs _ and severity is _
- Aggravating factors: _ (eating, movement)
- Alleviating factors: _ (defecation, reclination)
- Associated ROS: _
- Negative ROS: _ (fever, chills, dysuria, early satiety, hematochezia, constipation, decrease appetite, diarrhea)
- Associated medical history: _ (coagulopathy, diabetes, hypertension, renal stones, surgery, urinary tract infections, trauma)
- Associated family history: _ (inflammatory bowel disease, sickle cell anemia)
- Associated social history: _ (recreational drug abuse, tobacco abuse, travel)
- Associated sexual history: _ (intrauterine device use, sexually transmitted diseases)
