.qtaz

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.qtaz
Quick Text A to Z

• William Storo, MD
• Chairman, Department of Pediatrics
• Dartmouth Hitchcock Concord

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Benefits of Quick Text

• Document quickly/efficiently
• Document thoroughly
• Instantaneously available information avoid
  leaving room to find information
• Peripheral brain
• Avoid Transcription (no lag-time, information
  immediately available, cost savings)
• Utilize rather than fight technology
• Look smart (be smart)

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General Quick Text Principles

• Quick Text Dot-word longer text (by
  convention)
• Location Options Quick Text Define Quick
  Text for

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(No Transcript)
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(No Transcript)
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General Quick Text Principles

• Quick Text Dot-word longer text (by
  convention)
• Location Options Quick Text Define Quick
  Text for
• Global Use shortcuts already in Centricity
  system to enter lab results, forms, obs terms,
  various other texts (open as above, to review
  whats available under Global Use)
• Personal Use shortcuts created by user, Personal
  Quick Text overrides Global Quick Text If you
  choose the same name as a quick text already
  existing in the global list, your personal quick
  text will ALWAYS override the global use text

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General Quick Text Principles

• Repetitive Text using dot-name to stand for
  longer text any text used more than once that is
  more than a few words long is worthy of
  consideration for quick text
• Naming System create a convention - a way to
  organize and remember the name consider using
  the simplest word or name for the item, consider
  adding "hx" for history, "pe" for physical, "a"
  for assessment, p for plan or "tx" for
  treatment
• examples for viral uri .uripe .uria and .uritx

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General Quick Text Principles

• Accuracy
• ANY TIME A PROVIDER USES A SCRIPTED TEXT, THEY
  MUST INSURE THAT THE TEXT IS ACCURATE.
• Thus you may need to delete portions or insert
  additional text to complete the note.

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General Quick Text Principles

• Redundancy multiple names can be given to the
  same quick text information that you would like
  to insert. Thus, if you have trouble recalling
  which of several possible sensible names you
  called a given quick text, call it all the names
  you might use, such as
• .rsvtx .bronchiolitistx .wheezetx
  .wheezingtx
• If you think you have previously made a quick
  text, and cant remember the name, try to find it
  in your personal list. Once you find it, rename
  it with the few names you thought of for the text
  that werent working when trying to find it.

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General Quick Text Principles

• Nesting Quick Text
• - use if text is longer than 512 characters
  allowed
• - divide text into two (or more) quick text ,
  with the last line of the first quick text being
  the name (including the dot) of the next quick
  text
• - type name of 1st quick text, then enter or
  space bar
• - hitting enter or space bar again to insert
  the 2nd text
• - you dont have to remember the name of the 2nd
  text
• (its already provided for you at the end of the
  first)

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General Quick Text Principles

• Stacking Quick Text use multiple shorter quick
  text to customize notes
• .paintx acetaminophen or ibuprofen prn pain
• .rest relative rest, increasing activities as
  tolerated
• .crutches crutches provided, instructed on
  crutch-walking
• .heat discussed using heat (heating pad, warm
  compress, hot tub, bath, hot shower) to relax
  muscles
• .fu call if worsening, not improving

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General Quick Text Principles

• Stacking Quick Text use multiple shorter quick
  text to customize notes
• .paintx
• .rest
• .crutches
• .heat
• .fu
• acetaminophen or ibuprofen prn pain,
• relative rest, increasing activities as
  tolerated,
• crutches provided, instructed on crutch-walking,
  
• discussed using heat (heating pad, warm
  compress, hot tub, bath, hot shower) to relax
  muscles,
• call if worsening, not improving

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General Quick Text Principles

• .anklepe
• Relative rest decreasing wt bearing/activity
  as necessary to minimize pain ice 15-20
  minutes q1-2hrs x 24 hrs compress (ace wrap
  applied) maintain x 24-48 hrs elevate to
  minimize swelling when feasible ibuprofen
  tid-qid to minimize pain and swelling increased
  ROM as pain allows, then increased activity as
  pain allows, stepwise toward full
  activities/sports theraband given, exercises
  reviewed for eventual strengthening of ankle when
  pain allows ankle sprain handout given

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Phone Numbers

• Hospital numbers, ancillary services, referring
  physicians, programs
• .xray
• Hitchcock reading room x5064
• Concord Hospital reading room 88 x3415
• .lipidclinic
• Drs. Mary McGowan, MD, Laura Fox, MD, Susan
  Lynch, MD
• Cholesterol Treatment Center at Concord Hospital
• Memorial Building, Suite 210
• Concord, NH 03301
• 230-1920

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Resources

• Support groups, programs, websites
• .autismresources
• Autism Society of NH 679-2424
• www.autism-society-nh.org
• nhautism_at_yahoo.com
• Jumpstart individualized Supports for Young
  Children with Autism
• Ann Dillon 862-0793
• aedillon_at_cisunix.unh.edu
• Family Resource Connection 1-800-298-4321
• www.aap.org/policy/re060018.html (policy
  statement)
• www.firstsigns.org

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Resources

• .stuttering
• Stuttering Foundation of America
• 3100 Walnut Grove Road
• Suite 603
• P.O. Box 11749
• Memphis, TN 38111-0749
• 1-800-992-9392
• 1-901-452-7343
• www.stutteringhelp.org
• stutter_at_vantek.net

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Resources

• .sisupportgroup
• Dysfunction of Sensory Integration support group
• Child Family Services, 13 Green Street
  Concord, NH
• meetings 2nd Wednesday, monthly, from
  630-830pm
• contact Tina Moyer _at_ 798-3577,
  owen_at_localnet.com
• .sitherapy
• Pediatric Therapy and Wellness Center Sensory
  Integration, Autistic Spectrum, Pediatric Therapy
  (neurologic, musculoskeletal d/o)
• KIDZ PLAY PEDIATRIC THERAPY
• 1 F Commons Dr. 38
• Londonderry, NH 003053
• phone [phone]
• fax [phone]
• evaluator Erica Plante

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Resources

• .cap
• Central Auditory Processing testing centers
• Professional Hearing Management
• 44 Birch Street
• Derry, NH 03038
• Kathleen Loftus West
• Childrens Hospital at Lexington
• 482 Bedford Street
• Lexington, MA 02420
• 1-791-672-2100
• Boston Childrens Hospital
• 300 Longwood Avenue
• Boston, MA 02115
• 1-617-355-6042
• (need to be 7 yo, English speaking, previous
  neuropsych testing)

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History Gathering

• Assist with obtaining, documenting histories
• .lymehx
• rash duration
• rash appearance/? bulls-eye lesion
• recollection of tick bite
• increased time spent in wooded areas
• travel to high risk lyme disease areas
• ROSsystemic rash
• fevers
• emesis
• dyspnea, wheezing
• joint pain/swelling
• myalgias

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Review of Systems

• ROS Organization, Documentation
• .gerdros
• ROS
• sx worse with spicy, acidic foods
• sx worse after meals (especially large)
• sx worse at night
• sx worse with dairy, wheat intake
• sx improve with antacids or otc H2 blockers
• previous trial of proton pump inhibitors
• caffeine intake
• alcohol/tobacco use
• diarrhea/constipation
• weight loss
• family hx GERD/PUD
• family hx celiac disease, IBD

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Risk Assessment

• Reminders regarding risk groups, screening
  recommendations
• .diabetesrisk
• Risk factors for pre-diabetes (screen every 3
  years)
• obesity ( 120 of IBW, or BMI 27)
• first degree relatives with diabetes
• at risk ethnic groups African American,
  Hispanic, Native American
• HTN ( 140/90)
• Triglycerides 250
• impaired GTT or fasting glucose

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Risk Assessment

• .rsvrisk
• RSV risk factors/candidates for synagis
• prematurity
• 29-32 weeks,
• 32-35 weeks, risk factors
• chronic lung disease (CLD) requiring any of the following 6 months prior to
  RSV season supplemental oxygen, bronchodilators,
  diuretics, corticosteroids
• congenital heart disease (CHD) hemodynamically
  significant,
• other or immune function
• synagis/rsv clinics 695-2745 (Manchester),
  650-6244 (Lebanon),
• 663-3381 (Elliot)

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Risk Assessment

• .sportsrisk
• SPORTS PREPARTICIPATION RISKS
• Symptoms
• chest pain
• dyspnea w/exertion
• syncope
• Hx
• murmur
• HTN
• Family Hx
• early CAD
• sudden death
• Physical exam
• HTN
• presence of murmur
• Marfanoid habitus (arm span ht, long
  fingers, joint laxity,
• crowded teeth, lens detachment, pectus)

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Epidemiologic Information

• Available to inform, educate, reassure patients
• .westnile
• Discussed West Nile Virus epidemiology
• only handful of human infections reported in NH,
  with few deaths
• most infections are mild and often clinically
  unapparent
• 20 of those infected develop mild flu-like sx
  (fever, malaise, anorexia,
• nausea, vomiting, eye pain, h/a, myalgias,
  rash, lymphadenopathy)
• incubation period is 3-14 days, w/sx lasting 3-6
  days
• in
• even less develop life-threatening illness (more
  common in elderly, ill)

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Epidemiologic Information

• .sleepduration
• AVERAGE SLEEP DURATION IN CHILDREN
• Age Hours of Sleep/Day
• 1 wk 16.5
• 1 mo 15.5
• 3 mo 15.0
• 6 mo 14.25
• 1 yr 13.75
• 2 yrs 13.0
• 4 yrs 11.5
• 5 yrs 11.0
• 10 yrs 9.75
• teen (school) 7.5
• teen (summer) 9.0
• (AAP 2001)

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Physical Exam

• Reminders regarding directed exams
• .elbowpe
• extremities UE
• ROM shoulder
• elbow
• wrist
• elbow tenderness olecranon
• distal humerus
• elbow deformity/effusion
• Cozens test (pain w/dorsiflexion, c/w lateral
  epicondylitis)
• pain w/flexion (c/w medial epicondylitis)
• parasthesias (lateral aspect of hand ulnar
  neuritis)
• neurovascular strength
• sensation
• pulses

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Physical Exam

• .lipidstoragedz
• Symptoms Concerning for Lipid Storage Disease
  (LSD)
• head lag/floppy baby
• facial dysmorphisms
• eye abnormalities/corneal clouding
• enlarged tongue
• chronic rhinitis/upper airway obstruction
• cardiomyopathy/murmurs/valvular disease
• hepatosplenomegaly
• hernia (inguinal/umbilical)
• joint stiffness/decreased ROM
• joint deformities
• skeletal deformities
• skin rash

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Lab/Radiographic Guidance

• Directions regarding lab, xray evaluation of
  specific conditions
• .westnilelabs
• NH State Health Department West Nile Virus
  testing recommendations
• - age 2 years old
• - fever 38
• - evidence CNS involvement altered mental
  status, confusion, agitation, lethargy, seizures,
  focal neurologic findings
• - abn CSF profile suggesting viral etiology (hi
  protein, lymp pleocytosis)
• - muscle weakness (exam/EMG)
• recommended WNV testing serum, CSF IgM, IgG for
  WNV
• (pts recently vaccinated against or infected
  w/yellow fever, Japanese encephalitis, dengue
  flavaviruses may test false for WNV IgM)

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Lab/Radiographic Guidance

.kneerules Ottawa knee rules (radiograph trauma
to knee if any of following) - point tenderness
of patella - tenderness at head of fibula -
knee cannot be flexed to 90 degrees - knee is
unable to bear weight for 4 steps
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Diagnostic Guidelines

• Guidelines available to assist in diagnosis,
  documentation
• .depression
• DEPRESSION DSM-IV CRITERIA (5 of following, 6
  mo)
• depressed mood most of day (required)
• markedly diminished interest/pleasure in
  activities (required)
• significant wt loss/gain
• insomnia/hypersomnia, sleepy
• psychomotor agitation/retardation
• fatigue/energy loss
• strong feelings of worthlessness
• diminished ability to think/concentrate,
  indecisiveness
• recurrent thoughts of death/suicidal ideation
• AND sx cause clinically significant
  distress/impairment in functioning

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Assessment

• Differential Diagnosis reminders, documentation
  assistance
• .earhia
• Viral uri w/aom, increased likelihood B. lactam
  resistant H. flu given (risk factors)
• failed/recent amox tx
• concomitant conjunctivitis w/aom
• .refluxa
• Symptoms c/w benign neonatal ge reflux,
  w/possible esophagitis component good weight
  gain despite emesis no hx maternal/pt abx, thus
  c. diff. unlikely no evidence of pyloric
  stenosis unlikely formula allergy, though some
  degree of intolerance possible

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Assessment

• .tineacddx
• Tinea Capitis Differential Diagnosis
• - seborrheic dermatitis (no hair loss)
• - dandruff (no hair loss)
• - atopic dermatitis (lesions in flexural folds
  of neck, arms, legs)
• - psoriasis (nail changes and silvery scales on
  knees or elbows)
• - alopecia areata (no scaling and irregular or
  complete hair loss)
• - traction alopecia (hx tight braiding)
• - trichotilomania (hx obsessive hair
  manipulation)

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Treatment/Plan

• Treatment/plan reminders, documentation
  assistance
• .refluxtx
• discussed reflux precautions, including
• not overfeeding - decreasing feeding volumes
• keeping pt more upright after feedings - avoid
  pressure on abdomen
• burp gently, not aggressively
• can trial maalox 1/4 tsp qid prn
• call if worsening, or not improving, and
  consider
• - changing to hypoallergenic formula (Alimentum,
  Nutramigen)
• - changing to hypoallergenic cereal (Earth's
  Best, Healthy Times)
• - H2 blockers (Pepcid, Zantac) or proton pump
  inhibitors (Prevacid)
• - Upper GI, CBCD, CMP, stool cx, guiac, TTG, IgA

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Treatment/Plan

• .herpestx
• Oral/Skin Herpes Treatment
• primary outbreak acyclovir 400mg BID x 7-10
  days, valcyclovir 500mg BID x 1 day
• secondary outbreak acyclovir 400mg TID x 5
  days, valcyclovir 500mg BID x 5 days
• prophylaxis acyclovir 400mg BID, valcyclovir
  500mg BID
• return to sports (NCAA)
• no fever/malaise (primary outbreaks)
• no new primary lesions x 72 hrs prior to exam
• minimum 5 day antiviral tx prior to
  participation
• covering not allowed
• (The Physician Sporsmedicine, p35, July, 2004)

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Treatment/Plan

• .tineavtx
• apply selenium sulfide shampoo 2-3x/wk to rash
  areas, can also use antifungal creams prn
• consider systemic therapy for tinea versicolor
  ketoconazole tablets, 200mg, one tablet PO qd for
  5 days
• do not bathe, shower, swim for 24 hours after
  taking the medicine since it is excreted in the
  sweat, med is absorbed best when taken w/orange
  or grapefruit juice

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Anticipatory Guidance

• Anticipatory guidance reminders, documentation
  assistance
• .fattx
• Discussed prudent dietary changes (including no
  snacking while sedentary, decreased portion size,
  decreased calories from drinks, avoiding excess
  intake of high calorie foods), as well as
  increased activity level to manage weight gain

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Anticipatory Guidance

• .pitchcount
• Pitch Count Recommendations in Young Baseball
  Players
• Age maximum pitches/game
• 8-10 52/-15
• 11-12 68/-18
• 13-14 76/-16
• 15-16 91/-16
• 17-18 106/-16
• maximum games/wk 2/-0.6
• maximum practice pitches/day 30-40
• maximum innings/wk 4-10
• (source American Academy of Orthopaedic
  Surgeons 2003)

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Anticipatory Guidance

• .pitchtype
• type of pitch minimum age to learn pitch
• fastball 8/-2
• change-up 10/-3
• curveball 14/-2
• knuckleball 15/-3
• slider 16/-2
• forkball 16/-2
• screwball 17/-2
• (source Physician Sportsmedicine,
  27(6)87-92, 102, 1999)

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Public Health Recommendations

• .fluoridetowns
• NH Fluoride Program 271-3139 towns
  w/fluoridated public water supply Concord,
  Laconia, Manchester, Rochester, Dover, Durham,
  Portsmouth, Hanover, Lebanon, Conway, Lancaster
• .rochester
• Rochester high risk lead town fluoridated
  water
• .leadcap
• RECOMMENDED ACTION FOR CAPILLARY BLOOD LEVELS
• Pb guideline
• Pb 10-14 re-test w/cap or venous Pb w/in 6 mo
• Pb 15-19 confirm w/venous Pb w/in 3 mo
• Pb 20-44 confirm w/venous Pb w/in 1 wk
• Pb 45-69 confirm w/venous Pb w/in 2 days
• Pb 70 if symptomatic, admit to PICU for tx
  confirm w/venous Pb immediately
• (Childhood Lead Poisoning Prevention Program
  271-4507)

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Public Health Recommendations

• .leadwater
• For elevated lead in drinking water
• 1. Use bottled water for drinking (and cooking
  if the cooking requires lots of water use, such
  as boiling pasta or rice often etc)
• 2. Check venous lead levels on child who has not
  recently been tested (within the past 6 months),
  also check the HCT in children checked recently
• 3. Give the State of NH Lead Poisoning
  Prevention Program's phone [phone]) for
  further questions

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Public Health Recommendations

• .eeerecs
• NH DHHS Recommendations to Clinicians (9/04)
• Consider this diagnosis in a clinically
  compatible case in the
• appropriate setting. Laboratory testing is
  recommended and may be
• arranged by calling [phone] during
  business hours or (603)
• 271-5300 after hours.
• Prevention measures are equivalent to those
  for WNV, including
• avoiding mosquito bites, use of protective
  clothing and insect
• repellents, and environmental reduction of
  mosquito populations.
• .eeerecs2

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Public Health Recommendations

• .eeerecs2
• A vaccine is available and should be used to
  protect horses. There is
• no recommended vaccine for humans.
• Cases and suspect cases of human EEE should
  promptly be reported to
• the State or local health department.
  Consultation may be obtained at
• [phone] during business hours or (603)
  271-5300 after hours.

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Medication/Prescription Guidance

• Guidance in selecting medications on patients
  formulary (saving the trial and error of using
  the formulary in the custom medication menu,
  though use this as a double-check)
• .antidepressants
• NH PRESCRIPTION GUIDE (7/06 12/06)
  Antidepressants
• Anthem Effexor/XR, Lexapro, Paxil, Wellbutrin
  XL, Zoloft
• Cigna Effexor/XR, Wellbutrin XL, Zoloft
• Harvard Effexor/XR, Wellbutrin XL, Zoloft
• Medicaid bupropion (wellbutrin) incl. SA, SR,
  mirtazapine (remeron), fluoxetine (prozac),
  fluvoxamine (luvox), lexapro, paroxetine (paxil)
• not zoloft, celexa

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Phone Correspondence

• Creating text for common phone responses
• .bss-
• LAB RESULTS final BSS/strep cx negative will
  have nurses call family to inform, check on
  patient status
• .nongrpastrep
• LAB RESULTS final BSS/strep cx negative for
  group A strep (though positive for non-group A
  strep) will have nurses call family to inform,
  check on pt status (if improved pharyngitis, no
  tx necessary if still w/significant sore throat,
  would rx w/keflex 500mg bid x 5 days to hasten
  resolution of non-group A strep, though this
  infection should resolve spontaneously even
  without antibiotic treatment)

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Shortcuts

• Using shorter text or abbreviations to stand for
  longer text
• .scfe
• slipped capital femoral epiphysis (SCFE)
• .spondylo
• spondylolysis/spondylolysthesis
• .ibd
• inflammatory bowel disease (IBD ulcerative
  colitis, crohns disease)
• .gerd
• gastroesophageal reflux disease (GERD)
• .pandas

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Shortcuts

• .ankle
• ankle injury 959.7
• .injurycodes
• INJURY ICD9 CODES
• ankle, foot 959.7
• arm, shoulder 959.2
• back 949.1
• coccyx 959.1
• elbow 959.3
• finger 959.5
• foot, leg, toe 959.7
• hand 959.4
• hip 959.6
• neck, nose 959.09
• wrist 959.3

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Spell Check

• Create quick text definitions for commonly
  misspelled words, letting incorrect spelling or
  portion of word (without dot preceding text)
  correct spelling
• persistant persistent
• intermittant intermittent
• erysipilas, erisipilas, erisipelas erysipelas
• emperic, imperic, impiric empiric
• appart apart
• amitriptiline, amitryptiline, amitrip, amitryp,
  amytrip amitriptyline
• teh the

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Clinical Pearls

• from books, articles, conferences, consults -
  access at point of service, when seeing pt
  (consider citing reference/date)
• .birch
• allergens commonly associated w/birch allergy
  (55, usually fine if cooked)
• apple, peach, plum, apricot, kiwi, cherry,
  carrot, celery, potato, hazelnut
• .latex
• allergens commonly associated w/latex allergy
  (35)
• melon, banana, papaya, avocado, kiwi, plum,
  nectarine, passion fruit, chestnut, mango,
  sometimes wheat, tomato

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Clinical Pearls

• .rast
• RAST TESTING CUT-OFFS (in kU/L, w/PPV 95-100)
• egg 7 egg (infant) 2
• milk 15
• peanut 14
• fish 20
• soy 65 (30 for 73 PPV)
• wheat 80 (26 for 74 PPV)
• RAST TESTING CUT-OFFS (in kU/l w/NPV 85-95)
• egg
• milk
• peanut
• fish
• home challenge if hx not suggestive of allergy
• MD challenge if 0.35 (or strongly suggests allergy) and
• (J. All Clin. Imm. 2004)

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Clinical Pearls

• .autismflags
• AUTISM RED FLAGS
• no big smiles or other warm, joyful expressions
  by 6 mo
• no back-and-forth sharing of sounds, smiles, or
  other facial expressions
• by 9 mo
• no babbling by 12 mo
• no back-and-forth gestures, such as pointing,
  showing, reaching, or waving
• by 12 mo
• no words by 16 mo
• no 2-word meaningful phrases (w/o repeating) by
  24 mo
• any loss of speech, babbling, social skills at
  any age
• (provided by UNH, as adapted from 2001 First
  Signs, Inc. www.firstsigns.org)

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Quick Text Summary

• Document quickly, efficiently, thoroughly
• Instantaneously available information avoid
  leaving room to find information
• Peripheral brain look smart (be smart)
• Avoid Transcription (no lag-time, information
  immediately available, cost savings)
• Utilize rather than fight technology

52
Quick Text Summary

• Quick Text Dot-word longer text
• Global Use Quick Text
• Personal Use Quick Text
• Repetitive Text
• Naming System
• Accuracy
• Redundancy
• Nesting Quick Text
• Stacking Quick Text

53
Quick Text Summary

• Phone numbers
• Resources
• History gathering
• Risk assessment
• Epidemiologic information
• Physical exam
• Lab/Radiographic Guidance
• Diagnostic Guidelines
• Assessment

• Treatment/plan
• Anticipatory Guidance
• Public Health Recommendations
• Medication/Prescription Guidance
• Phone correspondence
• Shortcuts/spell check
• Clinical Pearls

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Comments Questions