Management samples




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Women’s Health & Family Planning

Shortcut Samples for use in Progress Notes in Medical Director


Shortcut

Description




MANAGEMENT SAMPLES

.BSA

Breast self awareness discussed

.CCH

Contraindications to combined hormonal contraception ^

.CFU

Contraceptive follow up in ^ weeks

.CHX

Contraceptive history ^

.CME

Contraceptive method explained.

Side effects & Contraindications discussed.

Cost discussed.


.CU

Condom usage ^

.CC

Current contraception ^

.IUD

LMP ^
Day of cycle ^

Usual Period ^

Consent given

ON EXAMINATION:

Cervix ^

Discharge ^

Uterus ^

Tenderness ^

Vagina cleansed with chlorhexidine

^ ml 1% Xylocaine to cervix.

Tenaculum applied. Uterus sounded to ^ cm

^ inserted.

Canal clear. Strings cut to ^cm

Observed post procedure.

Post insertion instructions given in writing and explained.

Will be effective in ^ days.

For removal by ^/^/^ .


.LQN

Liquid Nitrogen to warts - Minimum of x ^ freeze thaw cycles.

Natural history post freezing explained. Review prn.



.NAF

No adverse findings according to CHC checklist

.ANC

Discussed options for antenatal care

Referred to ^.

Antenatal screening - ^.

Advised of complications of early pregnancy.



.PD

Unintended pregnancy - will need time to consider options.

Pregnancy options discussed.

Pregnancy Options booklet given.


.PNC

Bleeding pattern since birth ^.

Perineal check - ^.




.POD

Pregnancy options discussed.

Considering termination of pregnancy.

Non-directional counselling given.

Pregnancy Options booklet given.




.PT

Pregnancy test Batch no. ^ .




Referred to ^ for ^ .

.REV

Presents for review of investigations taken at previous visit.

.TOP

Termination of pregnancy done at ^ at ^ weeks gestation.

^ complications following procedure.

Bleeding post procedure - ^.

Using ^ for contraception post - TOP.

Emotional state assessed - ^.


.VBL

P/V bleeding

Gynaecological history - previous episodes of abnormal vaginal bleeding and previous

investigations / management ^

Pap test history ^

Past history of gynaecological surgery ^

Obstetric history - parity ^

Menstrual history - LMP ^

Any presence of pregnancy symptoms ^

Age at menarche ^ and menopause ^;

Any Intermenstrual bleeding (IMB) ^

Usual cycle length ^ , duration ^ , presence of clots ^

Contraceptive Use - type, length of time used, any side effects ^

Sexual History ^

Any risk of sexually transmissible infections & blood borne viruses ^

Any post coital bleeding (PCB)^

Any family history of breast, endometrial or bowel cancer - ^

Any thyroid condition or any other medical condition - ^

Any past history of abnormal bleeding including known blood dyscrasias, coagulation defects, haemorrhage or bruising ^



.ww

Menstrual History ^

Current contraceptive use ^

Parity ^


Gravidity ^

Terminations ^

Miscarriages ^

Last Pap Test ^

Any abnormal pap tests ^

Significant gynae history ^

Breast check, last one ^

Smoker ^


History of clotting disorder ^

Family history of clotting disorder ^

History of migraines ^

Family history of migraines ^

Family history of cancer:


  • Ovarian ^

  • Uterine ^

  • Bowel ^

  • Other ^







COMMENT SAMPLES

.PR

Reminded when Pap test next due.

.SSEX

Safe sex discussed. Condoms given.

.RL1

Recall letter 1 sent

.RL2

Recall letter 2 sent

.RL3

Recall letter 3 sent






The difference between a Management shortcut and a Comment shortcut is the Management ones are inserted with a bolded Management: heading above them.


To insert the symbol ^ (called a caret) hold down the shift key and press 6 on your keyboard.

To move between carets when using the shortcut hold down the Ctrl and F5 keys simultaneously.


Alternatively, select the ^ icon from the progress notes page.

If these shortcuts have been downloaded (or emailed) you can copy them directly into Medical Director:




  1. Select the required text from this word document (by clicking and dragging your mouse over the required words) and then rightclick.

  2. Select Copy

  3. Open MD into the Progress Notes tab

  4. Click on either the Management or Comment tabs (depending on where you want the shortcut to appear)

  5. Select Add to List

  6. Rightclick and paste to insert the text you had previously selected.

  7. Add the shortcut name and save.




Compiled by Katrina Otto, Train IT Medical (0424 580 286) www.trainitmedical.com.au &
Margaret Windsor, DARTA Medical, 1800 154 011 www.darta.com.au

These samples are offered as ideas to assist clinicians in creating their own shortcuts.



Our thanks to the many doctors and practice staff who have contributed to this list. Updated January 2013



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