Richard Rathe, MD

Associate Professor of Family Medicine (ret.) and Medical Informatician
17
Aug


ShortNote – Clinical Shorthand 1.0

By •• 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:

  1. Include common abbreviations when they exist.
  2. Expand common but potentially dangerous abbreviations into plain text (qd, qod, etc. are often banned in written notes).
  3. Make the triggers (aka “shorts”) as mnemonic as possible.
  4. Prevent transformation of non-shorthand text. (A paragraph of plain text should generally pass through unchanged.)
  5. 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 symptoms 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
otc OTC medication otcs plural
tx treatment txs 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…

 

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