Is it possible to assign an order and diagnosis in order to create components in the History of the present illness, another component in a predetermined order within a default Physical exam, and another verbiage component in the plan section? Then enter another "trigger phrase" that results in another stack of information in each section, stacking upon the previous entries::
For Example : MRI Cspine ; R C6 radiculopathy - pain ; this entry would generate:
HPI - The patient reports progressive pain radiating into the right arm in a C6 pattern. The pain is aching to sharp and worsens with activity and straining. The pain increases with cervical extension. The pain varies from 4-8/10 and improved with rest and slight cervical flexion. The patient denies recent trauma, bowel / bladder incontinence or fixed focal weakness. The pain persists despite treatment with rest, NSAID use, heat, ice, activity modification and physician guided physical therapy exercises issued more than 6 weeks ago. The patient has been compliant with the prescribed program, but symptoms persist.
Physical Exam Section:
General - no overt distress
HEENT - atraumatic, normocephalic. Sclera anicteric. Nasal - oropharynx benign.
Neck - supple, trachea midline
Chest - No audible wheezes, respirations even and unlabored
Cardiovascular: - No JVD, no extremity pallor
Abdomen: soft, nonguarded, negative jar exam
Extremities - normal bulk and tone
Spine - **Posterior cervical tenderness and increased pain with cervical extension. Spurlings test positive to the right with pain into a C6 distribution.
Neurologic - alert, attentive, moves all extremities well without focal weakness, **decreased light touch sensation in a C6 distribution on the right", gait and station stable.
And finally, in the Plan section:
The patient has symptomatic cervical radiculopathy that interferes with his routine daily activities and rest. He has pain and numbness consistent with a C6 radiculopathy and provokes with Spurling's testing. I will order an MRI and plan on follow up to imaging."
Then enter the second plan and diagnosis: "Refill medications : Lumbar spondylosis" which would then add -
HPI - The patient has ongoing low back pain. THe pain is present all of the time and increases with activity and axial loading. The pain is focused at the lower lumbar region along the facet lines and limits the patients ability to rest. The pain increases with prolonged sitting and he reports that he is constantly shifting positions to manage the pain. With medications, he manages the symptoms and achieves his daily tasks.
In the PE section - It would add to the spine category ; Lumbar facet line tenderness and increased pain with lumbar extension.
and in the plan Category it would add: Lumbar facet syndrome - refill medications and plan on routine monitoring follow up.
The end result:
User entries
"MRI Cspine ; R C6 radiculopathy - pain / numbness"
"Refill medications : Lumbar spondylosis"
HPI - The patient reports progressive pain radiating into the right arm in a C6 pattern. The pain is aching to sharp and worsens with activity and straining. The pain increases with cervical extension. The pain varies from 4-8/10 and improved with rest and slight cervical flexion. The patient denies recent trauma, bowel / bladder incontinence or fixed focal weakness. The pain persists despite treatment with rest, NSAID use, heat, ice, activity modification and physician guided physical therapy exercises issued more than 6 weeks ago. The patient has been compliant with the prescribed program, but symptoms persist.
The patient has ongoing low back pain. THe pain is present all of the time and increases with activity and axial loading. The pain is focused at the lower lumbar region along the facet lines and limits the patients ability to rest. The pain increases with prolonged sitting and he reports that he is constantly shifting positions to manage the pain. With medications, he manages the symptoms and achieves his daily tasks.
Physical Exam Section:
General - no overt distress
HEENT - atraumatic, normocephalic. Sclera anicteric. Nasal - oropharynx benign.
Neck - supple, trachea midline
Chest - No audible wheezes, respirations even and unlabored
Cardiovascular: - No JVD, no extremity pallor
Abdomen: soft, nonguarded, negative jar exam
Extremities - normal bulk and tone
Spine - Posterior cervical tenderness and increased pain with cervical extension. Spurlings test positive to the right with pain into a C6 distribution. It would add to the spine category ; Lumbar facet line tenderness and increased pain with lumbar extension.
Neurologic - alert, attentive, moves all extremities well without focal weakness, **decreased light touch sensation in a C6 distribution on the right", gait and station stable.
Assessment and Plan
Cervical Radiculopathy
The patient has symptomatic cervical radiculopathy that interferes with his routine daily activities and rest. He has pain and numbness consistent with a C6 radiculopathy and provokes with Spurling's testing. I will order an MRI and plan on follow up to imaging.
Lumbar facet syndrome - refill medications and plan on routine monitoring follow up.