I’m looking for a WORD 2003 macro, template or form that I can take to work to allow me to type in a quick paragraph outlining my patients’ illness. Especially with this flu season, I type in the same basic series of symptoms for each patient and am looking to make this process quicker.
I’d like a simple method for data entry that, when done, will take a few keystrokes for data entry and then create or convert it to simple text that I can then Cut & Paste onto another data form or print up. Unfortunately, the work computers that I am required to use only have WORD 2003.
URI HPI Template:
(Fevers, Chills, sore Throat, Sinus congestion, Nasal congestion, chest cOngestion, Malaise, Headache, facial Pain, toothAche
Productive, (Green, Yellow, Brown, Clear, Nonproductive)
(Clear, Yellow, Green, Brown, blood-Tinged )
a. Delete if left blank
b. Precede last word with ‘and’ if more than two
c. Separate by commas if more than three
4. Time duration
5. Chief complaint
6. Associated symptoms: Fevers, Chills, sore Throat, Sinus congestion, Nasal congestion, chest cOngestion, Malaise, Headache, Pacial pain, toothAche
a. Typing the boldface letter will input the word
b. Delete if left blank
c. Precede last word with ‘and’ if more than two
d. Separate by commas if more than three
7. Cough: Productive, Green, Yellow, Brown, Clear, Nonproductive
a. Hitting P will type ‘productive cough’
b. Hitting G, Y, B or C will type ‘for [color] sputum
c. Hitting more than one color will hyphenate colors, EG “yellow-green sputum”
d. N will type ‘nonproductive cough’
e. Leaving this space blank will remove it from the paragraph and add ‘cough’ to negative symptoms.
8. Nasal discharge: Clear, Yellow, Green, Brown, blood-Tinged
a. Same as #7
b. If both this and cough are left blank, they will both be removed from paragraph and added to negative symptoms below
9. Negative symptoms: any of #6 not chosen and #7 and #8 if left blank
[Age] year old [Gender] with history of [History] who presents with [Time Duration] of [Chief complaint]. [Gender appropriate He or She] endorses [Associated symptoms]. [Gender appropriate He or She] complains of [cough] and [nasal discharge]. [He or She] does not complain of [negative symptoms.]
The doctor sees a 46 year old man with a history of pneumonia who has a cough with greenish-yellow sputum, fevers, sore throat, chills and a head ache. He has no other symptoms. This has been bothering him for 6 days.
After the interview, the doctor opens the WORD form and types:
6 days [tab]
F C T H [tab]
P G Y [tab]
After the last tab, the macro/form tabulates and creates a text paragraph that can be [Cut and Paste] onto a text box on another form or program:
46 year old man with history of pneumonia who presents with 6 days of cough. He endorses fevers, chills, sore throat and headache. He complains of productive cough for green-yellow sputum. He does not complain of sinus congestion, nasal congestion, chest congestion, malaise, facial pain, toothache or nasal discharge.