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.

I’ve also created a proof of concept web app to experiment with documentation in real time…