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Old 07-13-2012
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Computer Space Management of Patient Note

I have been typing and in almost all the cases my patient note space is not enough as in I run out of space. Please help.

Where can I get the old PN note to compare with the new one. I feel like the part of list initial diagnostic test (if any) for each diagnosis >>> is still confusing me.

Please help
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Old 07-13-2012
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Idea! Abbreviations

The easiest way to maximize on space and time is to learn and use mneumonics. When I have a lot of + findings that are pertinent to the case I find myself either writing Also + for a,b,c,d,e,f.... or just putting +a, +b,+c, -d if it is important that this finding is negative. Then if there are a bunch of negatives when I review systems I just write:
HPI: #yo M/F presents with #hour/day/wk/mo history of ...... Also presents with a, b, c .....
ROS: Negative except as stated above
MEDs: none, NKDA (or the meds he is taking or allergic too here)
PMH: no major illnesses, hospitalizations or trauma (or surgeries if there are none)
PSH: if + surgery history I write it here if negative I add above just to save some space and time
FH: even if there is something like Dementia and I am talking about a diarrhea case I just write noncontributory to save time and space. If it is important then I write it in- I don;t waste time writing mother and father in good health because its noncontributory
SH: Occupation, who they live with, and then if they smoke or drink I say how much here if they say no to them all I write : Denies smoking, EtOH or drugs


HOPE that helps a bit. Mostly its finding little words or common abbreviations. Takes practice and still having trouble in some cases but practice, practice practice that's what I am doing! GL
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