Transcriptionist SuperExport Format 1.0
{styles: [], class: '|template|, need: TRUE, title: "Progress Note (ICU)", author: "J Rick Adams, M.D.", viewState: '|styled|, labels: '|Palmedic|, text: "S: <subjective>
<ROS picker>

0: {Vital signs}
{Medications List (day #)}
{Procedures List (day #)}
VENT: {Insert Test ('Ventilator settings')}
PE: <Physical Exam picker>
Labs: {Tests List}
 
A: {Patient description} with {Problems List}.

P: <plan picker>
", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (complete)", author: "J Rick Adams", viewState: '|styled|, labels: '|_all|, text: "General: <ROS (general)>
Skin: <ROS (skin)>
ENT: <ROS (ENT)>
Pulmonary: <ROS (pulmonary)>
CV: <ROS (cardiac)>
GI: <ROS (GI)>
GU: <ROS (GU)>
Hematologic: <ROS (hematologic)>
Neuro: <ROS (neuro)>
Endocrine: <ROS (endocrine)>
Musculoskeletal: <ROS (musculoskeletal)>", appSym: NIL, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (chest pain)", author: "John R. Adams", viewState: '|styled|, labels: NIL, text: "<symbol:(-)> nausea, <symbol:(-)> diaphoresis", }

{styles: [], class: '|template|, need: TRUE, title: "ROS (CHF)", author: "J Rick Adams", viewState: '|styled|, labels: '|_all|, text: "<symbol:(-)> dyspnea on exertion; <symbol:(-)> orthopnea; <symbol:(-)> paroxysmal nocturnal dyspnea; <symbol:(-)> peripheral edema", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (depression)", author: "J Rick Adams", viewState: '|styled|, labels: NIL, text: "<symbol:(-)> sleep disturbance; <symbol:(-)> suicidal ideation; <symbol:(-)> weight changes; <symbol:(-)> depressed affect; <symbol:(-)> decreased energy", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (diabetes)", author: "John R. Adams", viewState: '|styled|, labels: NIL, text: "<symbol:(-)> polydypsia , <symbol:(-)> polyuria, <symbol:(-)> polyphagia, <symbol:(-)> vision complaints, <symbol:(-)> peripheral neuropathy, <symbol:(-)> hyperventilation, <symbol:(-)> dehydration", }

{styles: [], class: '|template|, need: TRUE, title: "ROS (meningitis)", author: "J Rick Adams, M.D.", text: "<symbol:(-)> headache; <symbol:(-)> fever; <symbol:(-)> chills; <symbol:(-)> malaise; <symbol:(-)> vomiting; <symbol:(-)> mental status changes; <symbol:(-)> nuchal rigidity; <symbol:(-)> photophobia", appSym: '|Palmedic:JRAd|, }

{styles: [], class: '|template|, need: TRUE, title: "ROS (HIV)", author: "J Rick Adams", viewState: '|styled|, labels: '|_all|, text: "<symbol:(-)> fever, <symbol:(-)> chills, <symbol:(-)> night sweats, <symbol:(-)> weight loss, <symbol:(-)> nausea, <symbol:(-)> vomiting, <symbol:(-)> headache, <symbol:(-)> scotoma, <symbol:(-)> diplopia, <symbol:(-)> dysphagia, <symbol:(-)> dyspnea, <symbol:(-)> cough, <symbol:(-)> diarrhea, <symbol:(-)> oral lesions, <symbol:(-)> adenopathy, <symbol:(-)> rash, <symbol:(-)> anorexia, <symbol:(-)> mental status change, <symbol:(-)> focal deficit, <symbol:(-)> seizure, <symbol:(-)> dysesthesia", }

{styles: [], class: '|template|, need: TRUE, title: "Physical Exam (complete)", author: "J Rick Adams", viewState: '|styled|, labels: NIL, text: "general: <physical exam (general)>
skin: <physical exam (skin)>
HEENT: <physical exam (HEENT)>
CV: <physical exam (CV)>
Iungs: <physical exam (lungs)>
abdomen: <physical exam (abdomen)>
extremities: <physical exam (extremities)> 
neuro: <physical exam (neuro)>
rectal: <physical exam (rectal)>", }

{styles: [], class: '|template|, need: TRUE, title: "Physical Exam (normal)", author: "John R. Adams", viewState: '|styled|, labels: NIL, text: "general: A&O x3
HEENT: NCAT, PERRLA, E0MI, sclera non-icteric, retina nL, ¿ papilladema, tympanic   membranes nL, mucosa pink and moist, neck supple with full ROM, ¿ lymphadenopathy, ¿ thyromegaly, trachea midline, car otid upstrokes 2+ bilaterally
CV: RRR without M/G/R
Lungs: CTA bilaterally
Abdomen: soft, NTND, normo-active bowel sounds, no masses, no HSM
Extremities: ¿ c/c/e, pulses 2+ throughout
Neuro: CN 2-12 grossly intact, strength 5/5 throughout, sensation intact, DTRs 2+/4 throughout", }

{styles: [], class: '|template|, need: TRUE, title: "physical exam (rash)", author: "J Rick Adams, M.D.", text: "a rash is located over the <location> |Anatomy|. It is characterized as <rash type>.", appSym: '|Palmedic:JRAd|, }

{class: '|macro|, multiple: TRUE, choices: ["The patient states {s/he} is feeling better today.","The patient states {s/he} is feeling worse today.","The patient states {s/he} feels about the same.","Events of last night noted.","Condition unchanged.",], title: "subjective", labels: '|_all|, }

{class: '|macro|, multiple: TRUE, choices: ["[ROS (complete)]","[ROS (chest pain)]","[ROS (CHF)]","[ROS (depression)]","[ROS (diabetes)]","[ROS (meningitis)]","[ROS (HIV)]","cardiac: <ROS (cardiac)>","endocrine: <ROS (endocrine)>","ENT: <ROS (ENT)>","general: <ROS (general)>","GI: <ROS (GI)>","GU: <ROS (GU)>","hematologic: <ROS (hematologic)>","musculoskeletal: <ROS (musculoskeletal)>","neurologic: <ROS (neuro)>","pulmonary: <ROS (pulmonary)>","skin: <ROS (skin)>",], title: "ROS picker", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["[Physical Exam (complete)]","[Physical Exam (normal)]","{Physical Exam}","{Physical Exam (admission)}","vitals: {Vital signs}","vitals: BP: |Number|/|Number|; P: |Number|; R: |Number|; T: |Number|","general: <physical exam (general)>","skin: <physical exam (skin)>","HEENT: <physical exam (HEENT)>","CV: <physical exam (CV)>","lungs: <physical exam (lungs)>","abdomen: <physical exam (abdomen)>","extremities: <physical exam (extremities)>","neuro: <physical exam (neuro)>","nodes: <physical exam (nodes)>","pelvic: <physical exam (pelvic)>","rectal: <physical exam (rectal)>",], dynamicSort: NIL, title: "Physical Exam picker", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<plan (anemia)>","<plan (CHF) >","<plan (diet)>","<plan (DVT)>","<plan (GI bleed)>","<plan (health maintenance)>","<plan (hypercoagulability)>","<plan (MI)>","<plan (migratory polyarthritis)>","<plan (RTC)>","<plan (stroke)>","<plan (syncope)>",], dynamicSort: TRUE, title: "plan picker", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> palpitations","<symbol:(-)> hypertension","<symbol:(-)> murmur","<symbol:(-)> chest pain","<symbol:(-)> dyspnea","<symbol:(-)> orthopnea","<symbol:(-)> PND","<symbol:(-)> edema","<symbol:(-)> cyanosis","<symbol:(-)> ascites",], title: "ROS (cardiac)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> heat intolerance","<symbol:(-)> cold intolerance","<symbol:(-)> sweating","<symbol:(-)> thirst","<symbol:(-)> hunger","<symbol:(-)> increased urination","<symbol:(-)> goiter","<symbol:(-)> impotence","<symbol:(-)> hyperpigmentation",], title: "ROS (endocrine)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> congestion","<symbol:(-)> cough","described as <cough type>","<symbol:(-)> coryza","<symbol:(-)> deafness","<symbol:(-)> diplopia","<symbol:(-)> ear pain","<symbol:(-)> epistaxis","<symbol:(-)> eyes itching","<symbol:(-)> headache","<symbol:(-)> hoarseness","<symbol:(-)> lymphadenopathy","<symbol:(-)> neck stiffness","<symbol:(-)> photophobia","<symbol:(-)> rhinitis","<symbol:(-)> sinus pain","<symbol:(-)> sore throat","<symbol:(-)> syncope","<symbol:(-)> tinnitus","<symbol:(-)> tooth pain","<symbol:(-)> vertigo","<symbol:(-)> visual loss","<symbol:(-)> voice changes",], title: "ROS (ENT)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> weight change","<symbol:(-)> fever","<symbol:(-)> night sweats","<symbol:(-)> weakness","<symbol:(-)> fatigue",], title: "ROS (general)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> nausea","<symbol:(-)> vomiting","<symbol:(-)> dysphagia","<symbol:(-)> heartburn","<symbol:(-)> hematemesis","<symbol:(-)> change in bowel habits","<symbol:(-)> melena","<symbol:(-)> bright red blood per rectum","<symbol:(-)> constipation","<symbol:(-)> diarrhea","<symbol:(-)> abdominal pain","<symbol:(-)> gas","<symbol:(-)> jaundice","<symbol:(-)> hepatitis",], title: "ROS (GI)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> frequency","<symbol:(-)> urgency","<symbol:(-)> hesitancy","<symbol:(-)> nocturia","<symbol:(-)> dysuria","<symbol:(-)> hematuria","<symbol:(-)> incontinence","<symbol:(-)> infections","<symbol:(-)> stones","<symbol:(-)> menopause","last period |Number| <time units> ago","<symbol:(-)> discharge",], title: "ROS (GU)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> bruising","<symbol:(-)> bleeding","<symbol:(-)> anemia",], title: "ROS (hematologic)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> joint pain","<symbol:(-)> stiffness","<symbol:(-)> arthritis","<symbol:(-)> gout",], title: "ROS (musculoskeletal)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> fainting","<symbol:(-)> blackout","<symbol:(-)> seizure","<symbol:(-)> paralysis","<symbol:(-)> local weakness","<symbol:(-)> numbness","<symbol:(-)> tingling","<symbol:(-)> memory loss",], title: "ROS (neuro)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> cough","<symbol:(-)> sputum production","<symbol:(-)> hemoptysis","<symbol:(-)> wheezing","<symbol:(-)> asthma","<symbol:(-)> bronchitis","<symbol:(-)> emphysema","<symbol:(-)> pleurisy",], title: "ROS (pulmonary)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["<symbol:(-)> rashes","<symbol:(-)> pruritis","<symbol:(-)> dry skin","<symbol:(-)> hair changes","<symbol:(-)> nail changes",], title: "ROS (skin)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["alert and oriented x3","in no apparent distress","appropriate for age","pleasant","cooperative","non-responsive","responds only to pain","appears older than stated age",], title: "physical exam (general)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["no rashes","<symbol:(-)> jaundice","<symbol:(+)> skin tenting","<symbol:(+)> skin thickening","<symbol:(+)> telangectasias","<symbol:(+)> petechiae","[physical exam (rash)]",], title: "physical exam (skin)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["normal","PERRLA","EOMI","sclera anicteric","sclera icteric","retina normal","retina wIth fibrinous exudates","¿ lymphadenopathy","<symbol:(-)> thyromegaly","mucosa pink and moist","tonsilar exudates","pharynx erythematous","poor dentition","tympanic membranes normal","cerumen impaction","disc margins sharp",], dynamicSort: TRUE, title: "physical exam (HEENT)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["regular rate and rhythm","no murmurs, gallops or rubs","PMI non-displaced","I/VI systolic murmur","II/VI systolic murmur","heard best over base","heard best over apex","tachycardic","bradycardic","irregularly irregular","<symbol> JVD","<symbol> S4","distant",], title: "physical exam (CV)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["clear to auscultation and percussion bilaterally","coarse crackles in bilateral bases","coarse breath sounds throughout","decreased breath sounds","<symbol> wheezes","<symbol> crackles",], title: "physical exam (lungs)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["soft","non-tender","non-distended","obese","tense","distended","no hepatosplenomegaly","normoactive bowel sounds","hypoactive bowel sounds","hyperactive bowel sounds","abdominal girth of |Number| cm","liver span of |Number| cm","<symbol:(-)> palpable spleen","<severity> pain on palpation of  <location> quadrant","voluntary gaurding","involuntary gaurding","<symbol:(-)> fluid wave","<symbol:(-)> shifting dullness","<symbol:(-)> rebound",], title: "physical exam (abdomen)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["no clubbing","no cyanosis","no edema","dorsalis pedis pulse 2+","posterior tibial pulse 2+","capillary refill < 2 seconds","trace edema","1+ edema","2+ edema","3+ edema","4+ edema","no splinter hemorrhages",], title: "physical exam (extremities)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["CN II-XII grossly intact","no focal abnormalities","sensation WNL","strength WNL","strength |Number|<symbol>/|Number| <location>","reflexes WNL",], title: "physical exam (neuro)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["anterior cervical: <node description>","axillary: <node description>","epitrochlear: <node description>","femoral: <node description>","inguinal: <node description>","occipital: <node description>","postauricular: <node description>","posterior cervical: <node description>","preauricular: <node description>","submandibular: <node description>","submental: <node description>","supraclavicular: <node description>","tonsillar: <node description>",], dynamicSort: TRUE, title: "physical exam (nodes)", outlineFormat: TRUE, labels: '|_all|, }

{class: '|macro|, multiple: TRUE, choices: ["vaginal mucosa pink and moist","vaginal mucosa atrophic","cervix without lesions","cervix not present","no discharge","<symbol> cervical motion tenderness",], title: "physical exam (pelvic)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["normal sphincter tone","no masses palpated","guiaic <symbol>","no stool in vault",], title: "physical exam (rectal)", labels: NIL, }

{class: '|macro|, choices: ["CBC","Fe studies","ferritin","folate level","reticulocyte count","TIBC","transferrin","vitamin BI2 level",], title: "plan (anemia)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["diuresis with Lasix","diuresis with Bumex","Zaroxolyn","K-Dur","initiate ACE inhibitor","monitor electrolytes",], title: "plan (CHF) ", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["Calorie restricted diet<tb>","Intake only clear liquids","High fiber diet explained","Avoid all milk products.","Weight losing diet explained.","Exercise program explained.","No swimmimg/No head immersion underwater for 5 days.","Force fluids to tolerance.","Gargle with warm salt water TID.","Use humidifier BID-TID",], title: "plan (diet)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["heparin titrated for a PTT of 2.0 to 2.5 times the control","coumadin 10 mg PO tomorrow and titrate to an INR of 2 to 3","bilateral angiodynograms",], title: "plan (DVT)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["NG tube to suction","H&H q 6 hours","transfuse 2 units PRBC","type and cross 2 units PRBC","EGD","colonoscopy",], title: "plan (GI bleed)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["cholesterol screen","fasting lipid profile","mammogram","Pap smear",], title: "plan (health maintenance)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["protein C & S","Factor V Leiden","antithrombin Ill","anticardliolipin","lupus anticoagulant","stop coumadin two weeks before testing",], title: "plan (hypercoagulability)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["CBC","hepatitis B antigen/antibody","AS0 titer","anti DNAase B","SF analysis","blood cx","urinalysis","SF, throat, skin lesion fluid cx for GC","Ceftriaxone 1g IV qD x 7d",], title: "plan (migratory polyarthritis)", outlineFormat: TRUE, labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["RTC to check the effect of the treatment.","RTC for an ear check & tympanometer.","RTC to check the lungs","RTC to check a UA & UC","RTC to check the sutures","RTC for a re-X-Ray.","RTC for a pelvic exam and wet mount.","RTC to F/U <tb><tb>for<tb>.","Continue previous medications.",], title: "plan (RTC)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["CBC","ESR","PT/PTT","glucose","CT scan of head","carotid doppler studies","echocardiogram","MRI scan of head","MRA scan of head","aspirin 325 mg PO QID","ticlopidine 250 mg PO BID","coumadin","heparin","careful control of blood pressure","insulin for control of blood sugars","angiogram","NP0 until speech evaluation",], title: "plan (stroke)", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["cardiac enzymes q 8h x 3","CBC","Chem 7","CT head","EEG sleep and awake","EKG","monitor bed","MRI head","orthostatic blood pressures",], title: "plan (syncope)", outlineFormat: NIL, labels: NIL, }

{class: '|macro|, choices: ["(+)","(-)","(?)","(n/a)","pending",], title: "symbol", labels: NIL, }

{class: '|macro|, choices: ["acute","chronic","non-productive","productive",], title: "cough type", labels: NIL, }

{class: '|macro|, choices: ["day(s)","hour(s)","minute(s)","month(s)","week(s)","year(s)",], title: "time units", labels: NIL, }

{class: '|macro|, choices: ["mild","moderate","severe","better","worse","the same",], title: "severity", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["caudal","dorsal","left","lower","middle","right","third","upper","ventral",], dynamicSort: TRUE, title: "location", labels: NIL, }

{class: '|macro|, multiple: TRUE, choices: ["soft","firm","hard","mobile","fixed","tender","non-tender","|Number| cm in diameter",], title: "node description", labels: '|_all|, }

{class: '|macro|, choices: ["absent","diffuse","erythematous","macular","maculo-papular","papular","petechial","well circumscribed",], title: "rash type", labels: NIL, }