CareAlign Tips, Tricks and Tutorials

Learn all things CareAlign and access your progress note templates below.

CareAlign Overview

Check out the basics of CareAlign. This video will walk you through the different views and help you understand the general structure of CareAlign.

Add Patients to your list

To get started with CareAlign, you’ll need to add patients to your list. This quick video walks you through creating a new patient or adding an existing patient to your list.

Using CareAlign For Task Management

CareAlign can be used for everything from simple task management to generating your progress notes. This video demonstrates how CareAlign makes it easy to quickly create and edit tasks, from any view.

CareAlign For Documentation

If you’re looking for a more robust tool that can help you write your care plan once, and use it for all of your documentation needs, then check out this video. It demonstrates using our patient wiki page to build your detailed care plan, creating discrete problem list, then using that information to generate your progress note

CareAlign FAQs

If you still have questions or suggestions for CareAlign, please reach out to us at help@CareAlign.ai

Why don’t I see the patient I just added on my list?

The patient you just created may not have been added to your list. Click on the “add patient” button at the top of the page & search for your patient using their first name, last name, &/or MRN. Click the “Visit Started” link to bring up the visit details. Once there, search for your list to add the patient as a primary or consult patient. See “How do I add a patient to a service” to see more detail.

How do I add a patient to a service?
    1. When first creating a patient, when you get to the “admit patient” window, in the bottom right section, search for your list where it says “Search Service.” Once you find your service, select it. Once you select it, your list will be added as the primary list (if there is no other list selected) or the consult list (if there is an existing primary list). You can switch a list between primary and consult using the radio buttons.
    2. If you are on a patient’s page already, click the area of the header just below the code status. It will bring up the same window as above, and you can follow the same process as in step 1.
    3. To remove a patient from your list, click the trash can next to your list name from the Admit Patient/Edit Visit pop up.
    How do I take a patient OFF my list?

    From the patient’s page, click on the middle of the header just below the code status. This will bring up the “Edit visit” window. Click the trash can next to your list name from the Edit Visit pop up.

    To remove a patient from your list, choose the trash icon.

    How do I keep a list of discharged patients?
    1. Create a new list, and name it whatever you want (ex: “Medicine 1A - Discharged”)
    2. Then, when you are discharging a patient, click on code status in the header on the patient page
    3. In the “Edit Visit” window, remove your current service (click the trash icon next to it) and add the NEW service you just created.
    Where do I find the list of available dot phrases and keyboard shortcuts?

    On desktop, click on the “Shortcuts” link, within the app to bring up the keyboard shortcuts and text expansions. The text expansions are also listed on the FAQ page, here.

    How do I request a new dot phrase?

    Easy! Just let us know what you want by using the feedback form to request a new dot phrase, or email us at help@carealign.ai.

    I want to create a new bundle for my team - how do I do that?
    1. Click on “Bundle” either from the home page or from within a problem.

    2. Once on the bundle screen, click “New”, this will allow you to create a new bundle.

    3. Add the items you want to include in your bundle (you can add A/P items or tasks). In this screen you can add highlights, flags to different items that you want to have added every time with the bundle. To make the bundle viewable by others, choose “viewable by others” before saving your bundle.

    Note: If you would like to make “official bundles” that are visible to everyone but only editable by certain people, please request “official bundle access” by emailing help@carealign.ai. This is useful for making a standard bundle for a unit or service that you want to make sure other people do not edit.

    I want to edit an existing bundle, but I’m not able to?

    If you are unable to edit a bundle, check if the bundle is marked as “official”. Only users with “official bundle” permissions are able to edit all bundles. If you have additional questions, please reach out to help@carealign.ai

    How do I add a bundle to my problem?
    1. From within a problem in the patient’s careplan/wiki click the “Bundle” button
    2. Search for the bundle you are looking for.
    3. Click on the bundle you want.
    4. This will show you all the potential bundle items to add to your problem.
    5. You can UNselect certain items so they don’t get added to your problem.
    6. Once you are done, click “Apply to Problem.”
    What is the best way to do a systems based plan?

    Users can create a system based plan in two different ways, using a bundle or using separate problems.

    See it in action here: https://www.youtube.com/watch?v=vezOAJ3ILDs

    Using a bundle (the faster and more condensed way):

    1. On the patient wiki, create a problem where you will put the systems based plan. You can call it ICU Care, for example.
    2. Within the problem, click the “+Bundle” button, search for systems based bundles by searching for the word “system.”
    3. Once you find the one you want, click on it and choose “add to problem.”
      ** Note if there are elements you do not want to add, simply uncheck them before you add the bundle to your problem.**
    4. This will create an A/P item for each system. Fill out your plan for each system. Keep in mind, you can flag any A/P as an FYI so that item shows up in every view for every user.

    Using problems (for a more detailed plan):

      1. On the patient wiki, create a separate problem/issue for each system.

    Regardless of how you build your plan, both can be easily pulled into your note using the “Actions” button. Additionally, you can take a snapshot of the patient’s care plan at any time by using the “Save & Sign” functionality.

    How do I do a simple sign out all from one view?

    By using the “Day View” you can add/update the one-liner and the data box as well as view/create/update FYIs and tasks. This allows you to manage your simple sign out on a single page.

    See the full process in action here: https://youtu.be/nWpmqAYJ8ds

     

    What comes into a note?

    By default, the one-liner, the subjective information box and active problems are brought into the note. You can choose to bring in the pending tasks.

    Where should I put a patient’s past medical history?

    You have several options for where to put PMH:

    1. You can put relevant PMH in the one liner: 74y/o F with h/o DM, HTN, CAD….
    2. In the “Data and other info” section (the 2nd box under the one liner box), you can keep information here that will not come into your progress note. This box is visible on all the list views as well. You can keep a section for the PMH here.
      1. There is a dot phrase you can use called “.HPI” for new admissions which can be helpful.
    3. For PMH/Chronic problems that you are actively managing (i.e. you want them to come into your progress note), you can create an “Active Issue” called “Chronic Problems being managed during this admission” and create an A/P item for each problem with a short plan.

    4. You can also create a separate problem for each chronic problem.  For more involved issues that you are managing in house (DM, HTN etc) we suggest keeping them as active issues.  For less active but good to know issues (h/o prostate ca etc) you can keep these as chronic problems.

    Where do I put FEN and PPx, L/D/A?

    There are a couple of options depending on what you prefer:

    1. You can make an acute problem named "Global" to report this information and have it print in the progress note. You can then make individual A/P items for FEN, PPx, etc.
    2. For surgical services, you can make information items within the main surgical problem for each of the following: diet, ppx, anticoagulation, etc.
    3. You can also make a problem called “Access/Lines/Tubes” to keep a list of all of these items for the patient and track any tasks that you may need to perform for them.

    How do I discharge a patient?
    1. Click on or around your patient’s visit information in the header bar to access the edit visit modal. Here you will see an option to  ‘End Visit’.
    2. When you select this, it will default the discharge date to today, though you can update that as appropriate.
    3. Once you have updated the discharge fields, you may click ‘End Visit’ to complete the process.
    4. This will take you back to the same visit’s page, and the wiki will still be there for you to work with. There will be an identifier under the patient’s visit information that reads ‘*Not in House’ to differentiate between patients with active visits and those with non-active visits.
    5. Now, you can move this patient’s visit to a discharge list, a follow up list, or remove this visit all together. You can do this by opening the edit visit modal again, where you can add or remove the patient's visit to different lists.
    6. Note - you will now see the visit end date, which is not editable, So please make sure you do not end the visit, until the patient has actually ended their visit.
    7. When you go back to the landing page, any patient visits that are not active, or have been discharged from the hospital, will be grouped at the bottom of the list in alphabetical order. Their location will now display as ‘No Active Visit’.
            How do I copy forward a patient's visit?
            1. You can start a new active visit for your patient a few different ways. 
            2. The first way is to click on any patient on your list who has ‘No Active Visit’ listed to the right of their name. 
            3. You will be directed to the patient wiki. Click on or around your patient’s visit information in the header bar to access the edit visit modal.
            4. Once a patient has been discharged the ‘Start New Visit’ button will be listed on the Edit Visit modal. By clicking on this button, you can add your patient to the same list or a new list, just as you normally would.
            5. The second way you can start a new active visit for your patient is by searching for your patient using the ‘+Add Patient’ button.
            6. To start a new visit for your patient again, click ‘Start Visit’ and create a new visit just as you would normally do. CareAlign will automatically bring forward your patient’s information such as name, MRN, DOB, Gender, Emergency Contact Information, and Allergies 
            7. Now to copy forward, click the “actions” button, on the patient page, and choose ‘Copy Forward from Previous Handoff.’
            8. Here are the things that WILL copy forward:
              1. Problem names
              2. Unchecked tasks (if you select this box)
              3. Info items within each problem, which will all become “historical” so you can quickly reference what happened last time.  If some of the information is still relevant to this admission, yu can simply click on the “a/p” icon and change the item from “historical” to “Current plan”
            9. What will NOT copy forward, is the one liner, data or subjective boxes. We found that often those fields were not updated after copying forward, and that could lead to potential errors. So, for now you will need to write them from scratch. 
            10. Once you click the copy forward option, you will see a list of the patient’s prior visits with the start and end dates, as well as which primary team they were on for that visit.
            11. If you are not sure which visit you want to copy forward, you can click on the different visits to see what was on the care plan, and choose the one you want to copy forward.
            12. Once you have the one you want, simply click “copy” and that’s it!
            13. You will now see the problems in your plan. If you click the “View History” button under a problem, you will see the prior visit’s information and a tag with when the information was copied forward and by whom. Anything marked as ‘Historical’ can be easily moved back to the current plan. You can do this by clicking on the Historical Icon and selecting ‘a/p Current Plan.’
                  How do I update information about my list?
                  1. Click on ‘List’ from the home page.
                  2. Click on ‘Create new list’ button to create a new service.
                  3. Create a new name for your service and add the team information for that service. We suggest creating lists at the level of the intern, so each intern can see their own list of patients.
                  4. Then the supervising resident or the attending on that service, can save all the lists for their team together, to see a consolidated list of all the patients they are following.
                  5. All of this information will be editable, so if you need to update the service name or add new members to your team, you can do that at any point. 
                  6. All members of your team can search for this newly created service and add the service to their own landing pages. That way, all members of your team will have the most up to date news on your patients throughout their whole shift.
                  How do I flag a task?

                  You can create a standardized way to flag tasks. Dr. Subha Airan-Javia recommends flagging night tasks as blue and day tasks as yellow. 

                  How do I mark a patient as sick?

                  If you’re worried about your patient, you can mark them as sick, so the entire team is aware of their status. This will change their name to red both on the patient wiki and in your list view.

                  How do I move tasks to be listed under other problems on on my care plan?

                  You can easily move tasks on your care plan to different problems at any time by clicking on the icon next to the task and click “more”. The Edit Task modal will pop up and you can select the new problem you would like your task to be listed under. 

                  How do I use colored flags to categorize the patients on my list?

                  You can use the colored flags to categorize your patients. For example - your patients that require a follow up could be flagged as yellow. For an inpatient setting, Dr. Airan-Javia suggests flagging patients that are ready for discharge as green.

                  How can my team plan for discharge?

                  Any item can be flagged as being related to discharge. This helps you plan as a team for discharge.

                  Any task related to discharge will be grouped under the 'Discharge Plan' section on the patient wiki. 

                  How do I create a new list?
                  1. On the home page, you will see the 'List' button, located in the top left corner of the screen.
                  2. Simply click this button to get started. You can search for existing lists here or create new ones for your team. 
                  3. When creating a new list, we suggest creating lists at the level of the INTERN so each intern can see their own list of patients. Then the supervising resident or the attending on that service, can save all the lists for their team together, to see a consolidated list of all the patients they are following.
                  4. CareAlign enables you to add details to your list, such as providing the team names and phone numbers. That way information is always readily available when you need it most. Creating patient lists reduces errors in handoffs, efficiently manages patient care, and celebrates collaboration.
                    How do I create a new patient visit?

                    You can easily start a new visit for any of your patients. Simply click the 'Add Patient' button and search for your patient by first and last name, and/or MRN #. If you do not see your patient listed, select the option to 'Create New.' From here you can easily update the details about your patient and their visit, including age, emergency contact information, location, and allergies. Once you have entered all of the necessary information, add that patient to your list and begin your visit!   

                    How do I add tasks from the list views?

                    You can easily update your one liner, data boxes, add new anticipatory guidance items, or add new tasks from the list views. All changes to your patient in the list views will also be reflected on the care plan. 

                    CareAlign Dot Phrases

                    CARE TEMPLATES
                    .fminpatienthpi – HPI – Family medicine template

                    .call – Please call *** with questions.

                    .micutriage – Template for Transfer Request into Unit

                    .tp – Tentative Plan:

                    .att – ATTENDING ADMISSION NOTE AND ADDENDUM

                    .dcmeds – Template for discharge medication plan

                    .dctemplate – Template for a discharge summary

                    .exam – Template for a general exam

                    .global – Global issues for progress note (vte/gi ppx etc)

                    .hpi – HPI for inpatient admission

                    .objective – Progress note – data template

                    .query – PDMP query statement

                    .rev – Labs and data reviewed.

                    .s – Progress note – subjective/overnight events

                    .sbp – systolic BP

                    .sh – Social History

                    .subjective-obj-headings – Progress note – simple subjective/objective headings

                    .subjective-simple – Progress note – simple subjective statement

                    .sum – SUMMARY OF COURSE: ***

                    .surg-data – Progress note – surgical exam and data

                    .trdata – Prgoress Note – Simple headings for data (used by trauma)

                    .ty – Consult – Thank you for the consult

                    .vs – Progress note template – Vital signs headings

                    .examsimple – Progress note template – Simple exam

                    .covconfirmed – Template for caring for a confirmed COVID patient

                    .nhhpi – HPI – Nursing Home

                    .wellbabymomhpi – Template for hpi for a pregnant mother’s exam

                    .wellbabyoneliner – Template for a one-liner for a pregnant mother’s exam

                    .psych-hpi – HPI – Psych template

                    CONSULT
                    .cs-fu – Template for a Consult follow up

                    .periop – Peri-op risk assessment template

                    .so – We will sign off, please call with questions.

                    .ty – Consult – Thank you for the consult

                    TELEHEALTH
                    .covtelehealth – Template for tracking COVID Symptoms in outpatients (telehealth)

                    .cgcovtrack – Template for tracking COVID symptoms

                    INTERDISCIPLINARY

                    .slp – Speech Language Pathology

                    .rtnonventicu – Resp Tech – Handoff template for non-vented patients

                    .rtventicu – Resp Tech – Handoff template for vented patients

                    .nh – nursing handoff

                    .nht – Nursing – Handoff Template

                    CARDIOLOGY
                    .2hb – Second degree heart block Type 1

                    .acs – Acute coronary syndrome

                    .afib – atrial fibrillation

                    .ar – aortic regurgitation

                    .as – aortic stenosis

                    .avm – arteriovenous malformation

                    .avr – aortic valve replacement

                    .c2v – CHADS2-Vasc

                    .cabg – coronary artery bypass graft

                    .cad – coronary artery disease

                    .cea – Carotid Endarterectomy

                    .chf – congestive heart failure

                    .dccv – Direct current cardioversion

                    .dhf – Acute on chronic diastolic heart failure

                    .eps – cardiac electrophysiology testing for

                    .etv – endoscopic third ventriculostomy

                    .hfpef – Heart Failure with preserved EF

                    .hfref – Heart Failure with reduced EF

                    .hl – hyperlipidemia

                    .htn – hypertension

                    .ica – internal carotid artery

                    .icm – Ischemic Cardiomyopathy

                    .ii – irregularly irregular

                    .mat – multifocal atrial tachycardia

                    .mi – myocardial infarction

                    .mr – mitral regurgitation

                    .ms – mitral stenosis

                    .nicm – Nonischemic Cardiomyopathy

                    .nstemi – Non-ST elevation MI

                    .nsvt – Nonsustained ventricular tachycardia

                    .pad – Peripheral Arterial Disease

                    .paf – Paroxsysmal Atrial Fibrillation

                    .pfo – patent foramen ovale

                    .psvt – Paroxsysmal ventricular tachycardia

                    .pvd – peripheral vascular disease

                    .ri – regularly irregular

                    .rvr – rapid ventricular rate

                    .sdhf – Acute on chronic systolic & diastolic heart failure

                    .shf – Acute on chronic systolic heart failure

                    .stemi – ST Elevation MI

                    .svt – supraventricular tachycardia

                    .tavr – Transcatheter aortic valve replacement

                    .tee – transesophageal echocardiogram

                    .tte – transthoracic echocardiogram

                    .vf – ventricular fibrillation

                    ENDO
                    .di – Diabetes insipidus

                    .dm – Cont to check fingerstick glucose, titrate medications as necessary and monitor for hypoglycemia.

                    .iddm – Insulin dependent diabetes

                    .nidm – Non-insulin dependent Diabetes

                    GI
                    .colo – colonoscopy

                    .div – diverticulitis

                    .egd – endoscopy

                    .esld – End stage liver disease

                    .gerd – gastroesophageal reflux disease

                    .nv – nausea and vomiting

                    .pud – peptic ulcer disease

                    .ugib – upper GI bleed

                    HEME
                    .ac – anticoagulation

                    .aocd – Anemia of chronic disease

                    .apls – Antiphospholipid Antibody Syndrome

                    .chase – f/u *** aPTT and repeat q6 hours (***x2)

                    .dvt – deep vein thrombosis

                    .plt – thrombocytopenia

                    .ssd – Sickle cell disease

                    .sst – Sickle cell trait

                    .vte – venous thromboembolism

                    ORTHO
                    .oa – osteoarthritis

                    .thr – total hip replacement

                    .tka – total knee arthroplasty

                    RENAL
                    .aki – Cont to monitor Cr and urine output, and avoid nephrotoxins.

                    .aockd – Acute on chronic kidney disease

                    .esrd – End stage renal disease

                    .hd – hemodialysis

                    .pd – peritoneal dialysis

                    TRANSPLANT
                    .mmf – mycophenolate mofetil

                    .tac – tacrolimus

                    .txp – transplant

                    EXAM
                    .cdi – clean, dry and intact

                    .mae – moves all extremities

                    .neuroexam – Template for a neuro exam

                    .nae – No acute events

                    .exam – Template for a general exam

                    .objective – Progress note – data template

                    .rev – Labs and data reviewed.

                    .sbp – systolic BP

                    .subjective-obj-headings – Progress note – simple subjective/objective headings

                    .vs – Progress note template – Vital signs headings

                    .examsimple – Progress note template – Simple exam

                    .doe – dyspnea on exertion

                    .nhfxn – Functional Status

                    DATE/TIME STAMP
                    .date – Adds todays date

                    .de – [Date] Day events: ***

                    .ne – [Date] Night events: ***

                    .now – Current date and time

                    .time – Enters current time

                    DISCHARGE TRANSITIONS
                    .dcplan – Discharge prep – statement for time spent prepping discharge

                    .covdispo – Template for discharging a COVID patient

                    .covdcprob – COVID Discharge Team

                    .dcmeds – Template for discharge medication plan

                    .dctemplate – Template for a discharge summary

                    .sum – SUMMARY OF COURSE: ***

                    NURSING
                    .nh – nursing handoff

                    .nht – Nursing – Handoff Template

                    CRITICAL CARE
                    .cc – Total Critical Care time spent: ***

                    .rtnonventicu – Resp Tech – Handoff template for non-vented patients

                    .rtventicu – Resp Tech – Handoff template for vented patients

                    .trstu – Global ICU Care

                    .vdrf – Ventilator Dependent Respiratory Failure

                    .covards – Template for a patient with COVID ARDS

                    ENT
                    .sinus – Template for care for sinus precautions

                    .tsa – Endoscopic transphenoidal approach

                    GU
                    .bph – benign prostatic hyperplasia
                    NUERO
                    .aed – antiepileptic drugs

                    .ceeg – continuous EEG

                    .cft – craniotomy for mass resection

                    .csf – cerebrospinal fluid

                    .cva – cerebrovascular accident

                    .cvd – cerebrovascular disease

                    .davf – dural arteriovenous fistula

                    .delirium – Derlirium mangement recs

                    .dw – discuss with

                    .edh – epidural hematoma

                    .evd – extraventricular drain

                    .hcp – hydrocephalus

                    .ich – intracerebral hemorrhage

                    .ino – internuclear opthalmoplegia

                    .iph – intraparenchymal hemorrhage

                    .it – intrathecal

                    .ivh – intraventricular hemorrhage

                    .lp – lumbar puncture

                    .mae – moves all extremities

                    .mca – middle cerebral artery

                    .mvd – microvascular decompression

                    .neuroexam – Template for a neuro exam

                    .nph – normal pressure hydrocephalus

                    .pbd – post bleed day #

                    .pcomm – posterior communicating artery aneurysm

                    .pica – posterior inferior cerebellar artery

                    .plif – posterior lumbar interbody fusion

                    .sah – subarachnoid hemorrhage

                    .sz – seizure

                    .tcd – Transcranial dopplers

                    .tia – Transient ischemic attack

                    .ams – altered mental status

                    .voe – vaso-occlusive episode

                    .vps – ventriculoperitoneal shunt

                    PSYCH
                    .psych-cs – Template for a Psych consult

                    .psych-hpi – HPI – Psych template

                    .depressionSA – Depression with suicide attempt management recs

                    .etohbzd – Template for Etoh/benzo withdrawal protocol

                    .hi – homocidal ideation

                    .si – suicidal ideation

                    RENAL
                    .aki – Cont to monitor Cr and urine output, and avoid nephrotoxins.

                    .aockd – Acute on chronic kidney disease

                    .esrd – End stage renal disease

                    .hd – hemodialysis

                    .pd – peritoneal dialysis

                    TRANSPLANT
                    .mmf – mycophenolate mofetil

                    .tac – tacrolimus

                    .txp – transplant

                    RHEUM
                    .djd – degenerative joint disease

                    .ra – Rheumatoid arthritis

                    .sle – Systemic lupus erythematosus

                    COVID TEMPLATES
                    .covhpiLONG – HPI template for Field Hospital Use

                    .covconsent – Patient consent to have information in TrekIT

                    .covtelehealth – Template for tracking COVID Symptoms in outpatients (telehealth)

                    .covconfirmed – Template for caring for a confirmed COVID patient

                    .contact – Template for notating a contact person/room phone

                    .covdispo – Template for discharging a COVID patient

                    .covards – Temple for a patient with COVID ARDS

                    .cgcovtrack – Template for tracking COVID symptoms

                    .covdcprob – COVID Discharge Team

                    BILLING
                    .advcar – xxx minutes were spent with the patient and family discussing advance care planning.

                    .dcplan – Discharge prep – statement for time spent prepping discharge

                    PHRASE SHORTCUT
                    .nhhpi – HPI – Nursing Home

                    .22 – secondary to

                    .bmi – Body Mass Index

                    .cb – complicated by

                    .cf – concerning for

                    .cont – Cont to monitor

                    .cw – consistent with

                    .dfcy – deficiency

                    .doa – day of admission

                    .ev – *** Event: ***

                    .fh – Family History

                    .fr – fire rescue

                    .fu – follow up

                    .goc – goals of care

                    .hct – head CT scan

                    .incfi – Incidental Findings

                    .lgib – lower GI bleed

                    .mva – motor vehicle accident

                    .na – not applicable

                    .nae – No acute events

                    .nhfxn – Functional Status

                    .nhglobal – Global Nursing Home Issues

                    .osh – outside hospital

                    .pmh – Past Medical History

                    .ppx – prophylaxis

                    .prot – protein calorie malnutrition

                    .psh – Past Surgical History

                    .pt/ot – Physical Therapy and Occupational Therapy

                    .pta – prior to admission

                    .pw – presents with

                    .sob – shortness of breath

                    .sp – status post

                    .tc – to consider

                    .usoh – usual state of health

                    NURSING HOME
                    .nhhpi – HPI – Nursing Home

                    .nhglobal – Global Nursing Home Issues

                    DERM
                    .derm – Template for dermatology consult
                    FAMILY MEDICINE
                    .sinus – Template for care for sinus precautions

                    .tsa – Endoscopic transphenoidal approach

                    .fminpatienthpi – HPI – Family medicine template

                    .fmbabyoneliner – Family medicine template for a baby one liner

                    .fmmomhpi – HPI – Family medicine template for OB recent birth

                    .fmmomoneliner – Family medicine template for a mother who recently gave birth one liner

                    GYN
                    .gynonc – Gyn – template for procedure

                    .gynonchx – Gyn – handoff template

                    NUERO
                    .aed – antiepileptic drugs

                    .ceeg – continuous EEG

                    .cft – craniotomy for mass resection

                    .csf – cerebrospinal fluid

                    .cva – cerebrovascular accident

                    .cvd – cerebrovascular disease

                    .davf – dural arteriovenous fistula

                    .delirium – Derlirium mangement recs

                    .dw – discuss with

                    .edh – epidural hematoma

                    .evd – extraventricular drain

                    .hcp – hydrocephalus

                    .ich – intracerebral hemorrhage

                    .ino – internuclear opthalmoplegia

                    .iph – intraparenchymal hemorrhage

                    .it – intrathecal

                    .ivh – intraventricular hemorrhage

                    .lp – lumbar puncture

                    .mae – moves all extremities

                    .mca – middle cerebral artery

                    .mvd – microvascular decompression

                    .neuroexam – Template for a neuro exam

                    .nph – normal pressure hydrocephalus

                    .pbd – post bleed day #

                    .pcomm – posterior communicating artery aneurysm

                    .pica – posterior inferior cerebellar artery

                    .plif – posterior lumbar interbody fusion

                    .sah – subarachnoid hemorrhage

                    .sz – seizure

                    .tcd – Transcranial dopplers

                    .tia – Transient ischemic attack

                    .ams – altered mental status

                    .voe – vaso-occlusive episode

                    .vps – ventriculoperitoneal shunt

                    OB
                    .fmbabyoneliner – Family medicine template for a baby one liner

                    .fmmomhpi – HPI – Family medicine template for OB recent birth

                    .fmmomoneliner – Family medicine template for a mother who recently gave birth one liner

                    .obantepart – OB Antepartum Handoff template

                    .obpostpart – OB Postpartum Handoff template

                    .wellbabymomhpi – Template for hpi for a pregnant mother’s exam

                    .wellbabyoneliner – Template for a one-liner for a pregnant mother’s exam

                    PULM
                    .cap – Community acquired pneumonia

                    .copd – chronic obstructive pulmonary disease

                    .doe – dyspnea on exertion

                    .hcap – Healthcare associated pneumonia

                    .osa – Obstructive sleep apnea

                    .phtn – pulmonary hypertension

                    .vdrf – Ventilator Dependent Respiratory Failure

                    .sob – shortness of breath

                    SURGERY
                    .w – Wounds/Lines/Tubes/Drains

                    .wbat – weight bearing as tolerated

                    .periop – Peri-op risk assessment template

                    .surg-data – Progress note – surgical exam and data

                    .trdata – Prgoress Note – Simple headings for data (used by trauma)

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