Docuplate Toolkit - Getting Started with Your Own Documentation

The following segments introduce some more realistic items that may be used when creating documentation. Taking time to familiarize yourself with this feature by playing/practicing can help provide context, making further learning faster and easier.

Starter Shortcuts

Starter Shortcuts

Subjective:              Sub-      

Objective:                Obj-          

Plan                          Pla-        

Follow Up:               Fol-      

 

Active Problems:    Act+

Inactive Problems  Ina-    

Surgeries                Sur-      

Allergies                   All-        

Family History         Fam-      

Tobacco                  Tobmu      

Alcohol                     Alc-      

Social History         Soc-    

 

Using Starters

To use these shortcuts, simply type the shortcut into the corresponding field, then press the spacebar. This will expand the shortcut.

Note: This guide is about getting started; the focus is on simple demonstration, not full support of comprehensive charting. These abbreviated terms are provided only to assist in getting started. They are not comprehensive, and are not intended to contain all the items you will use.

Additional Starter Shortcuts

Subjective:   Sub-, Sub--, Sub=, Subt, ROSX, ChiX, nexc, nexd and nexs

Objective:     Obj-, Objs, Objn, ObjX, ObjX1c, ObjX1n and ObjHA

Plan:              Pla-

Follow Up:    Fol-

 

Starter Docuplates

Starter Docuplates

Click Docutainers in the menu bar, then Click Docuplates (or Press F6). In the Docuplates Viewer, Type 2008+ in the Search  field/box, and Click the Search button.

Additional Starters - Comparing New Generation Docuplates

PhaC       - Pharyngitis or Sore Throat (Compressed)

GasC       - Gastroenteritis (Compressed)

InfC          - Influenza (Compressed)

URIC        - URI - Upper Respiratory Infection (Compressed)

DysC        - Dysuria (Compressed) Female Cystitis

IngToe     - Ingrown Toenail (Compressed)

Click on the docuplate description to select-highlight, then Click the Download button. Even though many of these docuplates may be associated with disorders rarely/never treated in your practice, they may be useful in helping provide insight into complementary/alternative work flows.

PhaNG     - Pharyngitis or Sore Throat (NG)

GasNG     - Gastroenteritis (NG)

InfNG        - Influenza (NG)

URIC         - URI - Upper Respiratory Infection (NG)

DysC         - Dysuria (NG) Female Cystitis

IngToe      - Ingrown Toenail (NG)

It may be helpful to reduce the complexity of a downloaded docuplate item. After inserting the NG docuplate/template, Press Control + F9 to perform a Remove Unused Items command. This will immediately simplify the docuplate/template encounter format, revealing the basic organization/framework suggested for the documentation process.

General Purpose Starters

General Purpose Starters

Also download the docuplate/template that has "Sta" as a Shortcut  and Start-Routine or Default as the Description. This can serve as a plain or generic starter for any type of encounter.

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