sunsetsystems wrote on Wednesday, January 04, 2006:
A surgeon friend of mine has suggested an approach for allowing docs to easily create their own custom clinical templates (encounter forms).
I would like to know what the doctors here think of it.
For a description with mockups go to http://sunsetsystems.com/wishlist.php and see the item ‘Customizable Clinical Templates’.
– Rod
www.sunsetsystems.com
drroller wrote on Tuesday, January 10, 2006:
You should take a look at this recent addition to Mirrormed(Clearhealth)
http://forums.mirrormed.org/index.php?topic=26.new;topicseen#new
It introduces an interesting template/documentation feature you may be able to use.
sunsetsystems wrote on Tuesday, January 10, 2006:
This sounds essentially like a keyboard macro processor. I’m reminded of ProKey from the days of MS-DOS. There are surely some equivalent utilities like that today for Windows and whatnot… seems a waste to do that in a way that’s specific to one application.
Or am I missing something?
– Rod
www.sunsetsystems.com
drroller wrote on Monday, January 16, 2006:
Here is the benefit–
You make a template for each type of examination, when in an encounter form you drop that template in by typing .newexam and a space, the template has blanks which are marked with ***, you can tab between the blanks which speeds your data entry.
Benefit 1- you can’t tab between blanks if you are using a windows macro program.
Benefit 2- The templates work with firefox on any platform, you don’t have to install software on the client computer.
Benefit 3- A standard template system for all EMR users, so everyone can share encounter templates.
xiaoanri wrote on Friday, April 11, 2008:
I am interested in creating more templates for practical use, especially i could not find a template for physical exam. where shoudl i get started? thank you! hui
drbowen wrote on Tuesday, April 15, 2008:
***Normal Office Visit***
PMH, medications, allergies were reviewed.
Physical Exam:
Vital signs were reviewed.
RESPIRATORY: The breath sounds are equal bilaterally with normal amplitude. There are no crackles, rubs, or wheezes.
CARDIOVASCULAR: The heart sounds are normal. There are no murmurs, rubs, clicks or gallops.
Impression:
1.
Plan:
1.
Samuel T. Bowen, MD
***Normal ENT visit***
PMH, medications, allergies were reviewed.
Physical Exam:
Vital signs were reviewed.
MOUTH, EARS, and NOSE: The tympanic membranes are pearly gray. The nasal mucosa is pink with no discharge. The oropharynx is pink with no tonsillar erythema or exudate. There was no evidence of abnormal masses or leukoplakia.
RESPIRATORY: The breath sounds are equal bilaterally with normal amplitude. There are no crackles, rubs, or wheezes.
CARDIOVASCULAR: The heart sounds are normal. There are no murmurs, rubs, clicks or gallops.
Impression:
1.
Plan:
1.
Samuel T. Bowen, MD
***Normal Female Examination***
PMH, medications, allergies, FH, SH and ROS were reviewed.
PHYSICAL EXAMINATION:
Vital signs were reviewed.
CONSTITUTIONAL:
EYES: The eyelids are normal and there is no scleral icterus. The pupils are round and equally reactive to light. The fundi are normal with no evidence of hemorrhages, microaneurysms or exudates. There are no cotton wool spots. There is no copper wiring or arteriolar narrowing.
MOUTH, EARS and NOSE: The tympanic membranes are pearly gray. The nasal mucosa is pink with no discharge. The oropharynx is pink with no tonsillar erythema or exudate. There was no evidence of abnormal masses or leukoplakia.
NECK: There is no adenopathy. There are no bruits. There is no JVD. There is no thyromegaly.
RESPIRATORY: The breath sounds are equal bilaterally with normal amplitude. There are no crackles, rubs, or wheezes. There is no tactile fremitus. There is no dullness to percussion.
CHEST: The breasts are free of abnormal masses. There is no nipple discharge or retraction. There is no skin retraction. The axillae are free of adenopathy.
CARDIOVASCULAR: The heart sounds are normal. There are no murmurs, rubs, clicks or gallops. The radial pulses are 2/4 and symmetric. The femoral pulses are 2/4 and symmetric with no evidence of bruits. The posterior tibial pulses and dorsalis pedis pulses are 2/4 and symmetric. The aorta has no mass and no audible bruits.
ABDOMEN: There is no abdominal tenderness. The bowel sounds are normal. There are no abdominal bruits. There is no hepatosplenomegaly. There are no palpable masses.
GROIN: There is no adenopathy. There are no masses. There are no direct or indirect hernias palpated.
RECTAL: There are no rectal masses and the stool is hemoccult negative.
GU: The external genitalia are normal. There are no adnexal masses or tenderness. The cervix is closed with no motion tenderness. The uterus is a small lemon size without tenderness.
SKIN: There is no focal abnormal thickening, rash or mass.
EXTREMITIES: The hands are pink with no evidence of cyanosis. The legs are normal with no evidence of edema or varicosities. The feet are pink with normal capillary refill and no cyanosis.
MUSCULOSKELETAL: There is no swelling, erythema or warmth of the joints of the fingers, wrists, elbows, shoulders, knees, ankles and toes. There is no tenderness of the cervical, thoracic or lumbar spine.
NEUROLOGICAL: The cranial nerves 2/12 were normal. The motor examination is 5/5 and symmetric. The deep tendon reflexes are 2/4 and symmetric.
Impression:
1.
Plan:
1.
Samuel T. Bowen, MD
***Normal Male Examination***
PMH, medications, allergies were reviewed.
PHYSICAL EXAMINATION:
Vital signs were reviewed.
CONSTITUTIONAL:
Eyes: The eyelids are normal and there is no scleral icterus. The pupils are round and equally reactive to light. The fundi are normal with no evidence of hemorrhages, microaneurysms or exudates. There are no cotton wool spots. There is no copper wiring or arteriolar narrowing.
MOUTH, EARS, and NOSE: The tympanic membranes are pearly gray. The nasal mucosa is pink with no discharge. The oropharynx is pink with no tonsillar erythema or exudate. There was no evidence of abnormal masses or leukoplakia.
NECK: There is no adenopathy. There are no bruits. There is no JVD. There is no thyromegaly.
RESPIRATORY: The breath sounds are equal bilaterally with normal amplitude. There are no crackles, rubs, or wheezes. There is no tactile fremitus. There is no dullness to percussion.
CARDIOVASCULAR: The heart sounds are normal. There are no murmurs, rubs, clicks or gallops. The radial pulses are 2/4 and symmetric. The femoral pulses are 2/4 and symmetric with no evidence of bruits. The dorsalis pedis pulses and posterior tibial pulses are 2/4 and symmetric. The aorta has no mass and no audible bruits.
CHEST: He has normal male breasts without evidence of masses. There is no axillary adenopathy.
ABDOMEN: There is no abdominal tenderness. The bowel sounds are normal. There are no abdominal bruits. There is no hepatosplenomegaly. There are no palpable masses.
GROIN: There is no adenopathy. There are no masses. There are no direct or indirect hernias palpated.
GENITAL: He has a normal circumcised penis. The testicles are nontender and are without masses. The epididymis is normal without swelling, induration or tenderness.
RECTAL: The rectal sphincter tone is normal. The prostate is firm, symmetric with no evidence of enlargement. The stool hemoccult is negative.
MUSCULOSKELETAL: There is no swelling, erythema or warmth of the joints of the fingers, wrists, elbows, shoulders, knees, ankles and toes. There is no tenderness of the cervical, thoracic or lumbar spine.
EXTREMITIES: The hands are pink with no evidence of cyanosis. The legs are normal with no evidence of edema or varicosities. The feet are pink with normal capillary refill and no cyanosis.
SKIN: There are no abnormal skin rash or masses. There is no focal, abnormal thickening.
NEUROLOGICAL: The cranial nerves 2/12 were normal. The motor examination is 5/5 and symmetric. The deep tendon reflexes are 2/4 and symmetric.
Impression:
1.
Plan:
1.
Samuel T. Bowen, MD
markleeds wrote on Wednesday, April 16, 2008:
Dr. Bowen,
I like your templates. May I add them to CAMOS for the initial installation? Do you have any more that you would be willing to share? I will credit you in a comment in each individual template.
I was playing with making the content box resizable to take up the whole width of the page for the purpose of editing larger bodies of text like these templates. I will put that feature back in to accommodate them.
drbowen wrote on Wednesday, April 16, 2008:
Dear Mark,
Sure. Go ahead. I have released these under the FDL (Free Document License) and published then on the wiki at:
http://www.oemr.org/modules/wiwimod/index.php?page=AreThereAnyTemplates&back=WiwiHome
I yo would like me to create more I will be glad to do this.
Sam Bowen, MD
rayaz wrote on Monday, April 21, 2008:
How do I access http://www.oemr.org/modules/wiwimod/index.php?page=AreThereAnyTemplates&back=WiwiHome.
Regards
drbowen wrote on Monday, April 21, 2008:
Dear Riaz,
Apparently the page access is being restricted for non-registrants. I will need to work on the permissions. In the meantime if you register at http://www.oemr.org/ you should be able to access the page.
Sam Bowen, MD
rayaz wrote on Monday, April 21, 2008:
Dear Dr. Bowen
Thanks for the very quick reply. I´ve already registered at http://www.oemr.org/ but am unable to find my way around to that particular page from there!
Regards
drbowen wrote on Tuesday, April 22, 2008:
The templates at http://www.oemr.org/ are the same as those listed above.
To get there just click on this link:
http://www.oemr.org/modules/wiwimod/index.php?page=AreThereAnyTemplates&back=WiwiHome
otherwise you can navigate there by:
Documentation (Wiki) --> Are There Any Templates?
Sam Bowen, MD
technotool wrote on Wednesday, April 23, 2008:
Hello Dr. Bowen,
I have logged in and registered at the oemr.org site but I am getting a “restriction” warning when I try to access the documentation wiki. Additionally, please let me know if you would like to possibly migrate to a drupal site (I run a few of these currently) or have any interest in adding some flash animation to the site to try and raise interest. I am very interested in promoting and developing this open source platform for physician’s practices. Thanks again for your hard work on this open source project.
Sincerely
Al
drbowen wrote on Wednesday, April 23, 2008:
Dear Al,
Thanks for letting me know. I have been trying to fix some permission problems on the wiki and I may have, unintentionally, made things worse. I view the web page from inside the firewall and sometimes this makes a difference and your letting me know is very helpful.
I apologize for the inconvenience. I will work on it.
I would certainly be interested in getting some administrative help with the site if you are volunteering?
Sam Bowen, MD
drbowen wrote on Wednesday, April 23, 2008:
I am due to upgrade the software on the wiki and may need to take this opportunity to do so while working on the wiki permission issue.
Sam Bowen, MD
technotool wrote on Wednesday, April 23, 2008:
GReat. I’ll contact you via email.
al