Re: [FPM-Discuss] FreePM-1.0b2

[Chason Hayes]

> I am ready for some templates now.  The best format for me to
> use is in a multiple choice type format with limited text entry
> (people don't like to type if they dont have to)  The data
> elements in the template should include a topic followed by
> relevant potential findings.  This should be done for both
> history and physical.  Then list your differential diagnosis
> for the presenting condition and finally a list of
> treatment/diagnostic options.  Feel free to create for follow
> up visits as well as new.
>
> Example:
>
> presenting condition:
> abdominal pain
>
> associated symptoms: nausea, vomiting, diarhea, fever, chills,
> melena, hematemesis
> onset: gradually, suddenly, after eating, after MVA etc
> duration:  ____ hours, days,weeks,months, year
> exacerbation: eating, hunger, exercise etc
> relieving: rest, eating, tums etc
>
> PE:
> skin: intact, draining sinus, healed scars.
> lymphatics: none, inguinal lymphadenopathy
> tenderness: none, mild, moderate, severe, periumbilical,
> epigastric, RLQ etc
> masses: RLQ, LLQ, hepatomegaly, splenomegaly etc
> sounds: absent, tinkling, hyperactive etc
> special test: rebound, resonance to percussion
>
> Test:
> abdominal xray: free air under diaphram, renal calculi etc
> US: whatever
>
> Differential: gastroenteritis, cholecystitis, perforated ulcer,
> appendicitis, colon cancer etc
>
> Plan: CT scan, US, CBC, exploratory laparotomy,
> cholecystectomy, appendectomy, V+P, whipple whatever.
>
>
> To see an orthopedic template in action go to :
> http://www.freepm.org:8080/FreePM/emr/
>
> open up a patient account or create a new one
> in the top frame click encounters
> in the left frame select knee
> again in the left frame chose history, physical, etc
> when finished filling out the template at the bottom of the
> left frame click generate patient note.
> You can visit as many templates as you want in this fashion.
> When done, in the bottom of the right frame click save.
>
> The results of your work will appear in the right frame.  You
> can edit here or save and edit later or accept and sign off.

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