rathe.medinfo.ufl.eduRichard Rathe, MD - College of Medicine, University of Florida

Richard Rathe, MD Associate Professor of Family Medicine (ret.) and Medical Informatician 22 Jun closed An Alternative Symptom Score to Replace the Overused 10 Point Pain Scale By Richard Rathe •• Posted in HPI I was taught in medical school that pain scores were only useful for tracking progression/remission for individual patients. In my opinion it was a fundamental mistake to apply this tool as an objective “vital sign” across all patients. It simply doesn’t work that way. Scores remove context! I grew up medically with an implicit 3 point scale: mild, moderate, severe. In later years I pondered why I still preferred this over the newer 10pt version. I decided it was because a 3pt scale is easy to tie to function : mild=annoying, mod=disruptive, severe=disabling. I’d bet the average patient views their condition in terms similar to this rather than “my pain a 6 or a 7 out of 10.” If you take the 3pt functional symptom scale and couple it with a 3pt frequency scale : intermittent, frequent, constant—then you have a 3×3 grid that might be more meaningful than a one dimensional 10pt scale. -- Tweet Tagged as: clinical documentation , pain 17 Aug closed ShortNote – Clinical Shorthand 1.0 By Richard Rathe •• Posted in EMR , HPI , Patient Care I have worked with home-grown and commercial Electronic Medical Records for over thirty years. The use of “ dot commands ” (a period followed by a trigger phrase) is about as old as personal computing. (I first encountered dot commands in the WordStar word processing program during the 1980s!) These commands generally fall into three categories: a) links to retrieve data (name, age, lab values, etc.), b) links to specialized services or applications and c) macros that expand into “canned” text . I’ve always found the later somewhat cumbersome and an impediment to fluent typing. While working on a new set of macros for my Rational HPI Project , it struck me that all those periods were getting in my way . (I can touch type but special characters generally slow me down.) This is particularly true when using many short fragments. I decided to experiment with a standardized clinical shorthand based on these criteria: Include common abbreviations when they exist. Expand common but potentially dangerous abbreviations into plain text (qd, qod, etc. are often banned in written notes). Make the triggers (aka “shorts”) as mnemonic as possible. Prevent transformation of non-shorthand text. (A paragraph of plain text should generally pass through unchanged.) Limit punctuation and the need to use modifier keys (i.e., shift, alt, control, etc.). This is especially important for handheld devices such as tablets and smartphones. My first attempt resulted in approximately 130 Shorts (listed below). Note that I’ve repurposed the article ‘a’ and the pronouns ‘I’ and ‘us’ , since they have very little value in problem-focused notes. The goal is to generate functional documentation with the fewest keystrokes —not flowing paragraphs. Typing all lower-case is assumed but not required. Capitalization is only enforced for canonical abbreviations (HPI, ROS, RUQ, etc.) and certain keywords that are frequently missed (NO, NOT, LEFT, RIGHT). Punctuation is optional and should be kept to a minimum. How much punctuation to add automatically is an unsettled issue. At this time I include colons when a list is expected and commas for certain qualifying phrases. This is subject to change. I have an expanding number of disease and symptom shorts that are not listed here. Ultimately these may need to be specialty specific. Finally, certain phrases are included to support the needs of billing and compliance. Clinical Shorthand v1.0 ‘99′ indicates any number and ‘zz’ any phrase. Time unit ‘i’ indicates m(i)nute. Other time units are what you’d expect. Prolog 99 f 99yo female 99 m 99yo male hx history of cc presents with ccn presents with new cco presents with onging ccc presents with chronic Time 0d a few days 0 = a few 99d 99 days 99xd 99 times a day e99d , episodes lasting 99 days s99d , started 99 days ago s=sec i=min d=day w=week m=mon y=year Time (latin derived) qd daily bid twice daily tid three times daily qid four times daily qod every other day ac before meals pc after meals hs at bedtime Location l LEFT r RIGHT ls LEFT-sided rs RIGHT-sided bi bilateral ce central df diffuse an anterior po posterior me medial la lateral luq LUQ ruq RUQ llq LLQ rlq RLQ eg epigastic pu periumbilical sp suprapubic rad , radiates to ran , no radiation Onset (os) osg , gradual onset osi , insidious onset oss , sudden onset osu , unknown onset Progression (pg) pgu , unchanged pgr , resolved pgv , comes and goes v = variable pgb , gradually getting better pgbr , rapidly getting better pgw , gradually getting worse pgwr , rapidly getting worse Severity (sv) svi mild svm moderate svs severe sv9 9 out of 10 sva , an annoyance functional for ‘mild’ svh , a hindrance functional for ‘moderate’ svd , disabling functional for ‘severe’ Symptoms (sx) sx symptom sxs plural sxa associated symptoms: list sxn pertinent negatives: list sxr associated symptoms (see ROS) include ROS in HPI for billing sxo all other relevant systems are negative include ROS in HPI for billing Miscellaneous px problem pxs plural lx lab test lxs plural rx prescription rxs plural mx medication mxs plural tx treatment txs plural otc OTC medication otcs plural stx self-treatment ptx physical therapy otx occupational therapy rtx respiratory therapy pt patient pts patient’s ds disease sd syndrome ed emergency department er emergency department synonym hsp hospital dc discontinue dch discharge prn as needed xr xray cxr chest xray im imaging us ultrasound rf risk factors: list al allergies: list nka no known drug allergies synonym nkda no known drug allergies hpi HPI ros ROS pmh PMFSHx past med/fam/soc history src history from patient hxr relevant past medical, family and social history reviewed with the patient Modifiers un unknown nl normal ab abnormal eq equal ue unequal vr variable gt greater than lt less than ag aggravated by tg triggered by rl relieved by Smoking (sm) smn never smoker smk current smoker smk99 current smoker, 99py history smf former smoker smf99 former smoker, 99py history smq current smoker, ready to quit, discussed smoking cessation smq99 current smoker, 99py history, ready to quit, discussed smoking cessation smc current smoker, discussed smoking cessation smc99 current smoker, 99py history, discussed smoking cessation Single Letter Connectors a before latin ‘ante’ c with latin ‘cum’ e and latin ‘et’ f from i within n NOT o or p after latin ‘post’ r recent s without latin ‘sine’ t to w with synonym x except Units 99u 99 units 99iu 99 international units Negation -zz NO zz I’ve also created a proof of concept web app to experiment with documentation in real time… -- Tweet Tagged as: clinical documentation , clinical shorthand , text macros 12 Apr closed Exemplary Teacher Award 2016 By Richard Rathe •• Posted in Teaching Thanks to My Students & Colleagues! -- Tweet Tagged as: bedside teaching , lectures 11 Aug closed Patient Instructions Card with Advice on Common Problems By Richard Rathe •• Posted in Medicine , Patient Care Patients who are actively engaged with their health have better outcomes. Good communication is key. I made this Patient Instructions Card about six months ago and have been very pleased with it. I’ve turned it into a generic PDF with custom name, phone and tobacco resource fields. Fill in your particulars and have it printed at 50% on card stock. Enjoy! The front has lots of blank space to write on… The back has advice on common problems… -- Tweet 30 Jan closed QuickHPI v1.2 – Fully Functional Client-Side Web App By Richard Rathe •• Posted in EMR , HPI , Teaching This is the first release of quickHPI for general use by students, residents and clinicians. It is based on version 1.1 with persistent client-side data storage added. Once installed, it can be used o...