4 * forms/eye_mag/help.php
6 * Help File for Shorthand Entry Technique on the Eye Form
8 * Copyright (C) 2016 Raymond Magauran <magauran@MedFetch.com>
10 * LICENSE: This program is free software: you can redistribute it and/or modify
11 * it under the terms of the GNU Affero General Public License as
12 * published by the Free Software Foundation, either version 3 of the
13 * License, or (at your option) any later version.
15 * This program is distributed in the hope that it will be useful,
16 * but WITHOUT ANY WARRANTY; without even the implied warranty of
17 * MERCHANTABILITY or FITNESS FOR A PARTICULAR PURPOSE. See the
18 * GNU Affero General Public License for more details.
20 * You should have received a copy of the GNU Affero General Public License
21 * along with this program. If not, see <http://www.gnu.org/licenses/>.
24 * @author Ray Magauran <magauran@MedFetch.com>
25 * @link http://www.open-emr.org
30 include_once("../../globals.php");
31 include_once("$srcdir/acl.inc");
32 include_once("$srcdir/lists.inc");
33 include_once("$srcdir/api.inc");
35 $form_folder = "eye_mag";
36 $showit = $_REQUEST['zone'];
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173 <body style
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174 <div style
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179 background-color:#C9DBF2;
181 font-family: FontAwesome;
185 <img
class="little_image left" height
="18" src
="<?php echo $GLOBALS['webroot']; ?>/sites/default/images/login_logo.gif"></img
> OpenEMR
: Eye Exam
<span
class="bold">Shorthand Help
</span
>
188 <button id
="general_button">Introduction
</button
>
189 <button id
="hpi_button">HPI
</button
>
190 <button id
="pmh_button">PMH
</button
>
191 <button id
="external_button">External
</button
>
192 <button id
="antseg_button">Anterior Segment
</button
>
193 <button id
="retina_button">Retina
</button
>
194 <button id
="neuro_button">Neuro
</button
>
195 <div id
="container" name
="container_group" style
="margin:10;text-align:left;">
197 <div id
="accordion_general_group" name
="accordion_group" class="ui-accordion" style
="text-align:left;margin:10;padding:20;">
198 <h3
class="ui-accordion-header external">Introduction
: Paper vs
. EHR
</h3
>
199 <div id
="general" style
="text-align:left;">
200 <blockquote
class="style2">
201 <b
>"Documenting an exam on paper is faster because we develop our own shorthand."</b
><br
/>
202 Starting with this
"paper" shorthand
, we forged an electronic Shorthand
, specifically designed
for rapid data entry
.<br
/>
203 Using Shorthand
, all your findings are entered in one text box
,
204 and OpenEMR automatically knows how to store them
.<br
/><br
/>
205 The structure is simple
: <b
>Field
:text
;Field
:text
;Field
:text
</b
><br
/><br
/>
206 Click on any
<b
>Shorthand
</b
> icon
<i
class="fa fa-user-md fa-sm fa-2" name
="Shorthand_kb" title
="Open the Shorthand Window and display Shorthand Codes"></i
> in the Eye Form
and two things occur
:<br
/>
208 <li
> The Shorthand
<b
>textbox
</b
> opens
</li
>
209 <li
> Shorthand
<b style
="color:red;">Field
</b
> names are visible
</li
>
212 In the Shorthand textbox
, type the
<b
>Field
</b
> name
, then a colon
, followed by your findings
.
214 Look around the form
- openEMR
: Eye Exam is automatically filled
.<br
/>
215 Done
. No extra clicks
.<br
/>
218 This tutorial shows you how to document each area using Shorthand
. <br
/>
219 We
'll show you how to complete the HPI, PMH, POH, Medication list, Surgical History and Allergies.<br />
220 As an example, using a handful of lines of typing in the Shorthand textbox,<br />
221 you will document all your normal findings <b>and more than 40 different clinical issues</b>.
223 That's a lot to document
and one mighty complicated patient
!<br
/>
224 Combined it may be many more issues than we would see on a routine day
, with routine patients
, but it could happen
... <br
/>
225 Documenting this many findings would take a little bit of time on paper
, and a lifetime in a typical EHR
. <br
/>
226 The average typist can now
do it
<b
>in less than a minute
.</b
> A normal encounter can be accurately documented in seconds
.
229 <h4
class="bold">HPI
: </h4
>
230 <textarea
class="kb_entry">D
;CC
:"My eyes are tearing and there is a yellow discharge";hpi
:The symptoms began last week
and the discharged turned yellow yesterday
. No photophobia
. The redness spread from the right to the left eye two days ago
.;</textarea
>
231 <button id
="hpi_button2">Details
</button
>
233 <h4
class="bold">PMH
: </h4
>
234 <textarea
class="kb_entry">POH
: POAG
.Myopia
. Dry Eye
; POS
:Phaco
/IOL OD
4/4/1994.Phaco
/IOL OS
4/24/1995. Yag
/PCO OD
6/5/1999;Meds
:Timolol
0.5% GFS QHS OU
. Latanoprost
0.01% QHS OU
.
235 Trazadone
50mg PO QHS
.Famvir
500mg PO TID
;Surg
:Appendectomy
1998. Choly
2010.Lap Band
2014.;All
:sulfa
- hives
.PCN
- SOB
;</textarea
>
236 <button id
="pmh_button2">Details
</button
>
239 <h4
class="bold">External
: </h4
>
240 <textarea
class="kb_entry">D
;bll
:+
2 meibomitis
;rll
:frank ect
, 7x6mm lid margin bcc lat
.a
;bul
:2mm ptosis
;rul
.+
3 dermato
.a
</textarea
>
241 <button id
="external_button2">Details
</button
>
242 <br
/><h4
class="bold">Anterior Segment
:</h4
>
243 <textarea
class="kb_entry">D
;bc
:+
2 inj
;bk
:med pter
;rk
:mod endo gut
.a
;bac
:+
1 fc
, +
1 pig cells
</textarea
>
244 <button id
="antseg_button2">Details
</button
>
247 <h4
class="bold">Retina
:</h4
>
248 <textarea
class="kb_entry">D
;bd
:+
2 bowtie pallor
;rcup
:0.6Vx0
.4H w
/ inf notch
;lcup
:0.5;rmac
:+
2 BDR
, +CSME
;lmac
:flat
, tr BDR
;v
:+PPDR
, ++venous beading
;rp
:ht
1 o
,no vh
;</textarea
>
249 <button id
="retina_button2">Details
</button
>
251 <h4
class="bold">Strabismus
:</h4
>
252 <textarea
class="kb_entry">scDist
;5:8ix
1rht
;4:10ix
;6:6ix
;2:15xt
;8:5ix
;ccDist
;4:5ix
;5:ortho
;6:ortho
</textarea
>
253 <button id
="neuro_button2">Details
</button
>
256 Below all these lines are strung together
. Copy
and paste this into a test patient
's chart. <br />
257 Voila! HPI, PMH, POH, Medications Allergies and 40 clinical findings + normals, are documented.
260 <textarea class="kb_entry" style="height:2.3in;">CC:"My eyes are tearing and there is a yellow discharge";hpi:The symptoms began last week and the discharged turned yellow yesterday. No photophobia. The redness spread from the right to the left eye two days ago.;
261 POH:POAG. Myopia. Dry Eye; POS: Phaco/IOL OD 4/4/1994.Phaco/IOL OS 4/24/1995. Yag/PCO OD 6/5/1999;Meds:Timolol 0.5% GFS QHS OU. Latanoprost 0.01% QHS OU.
262 Trazadone 50mg PO QHS.Famvir 500mg PO TID;Surg:Appendectomy 1998. Choly 2010.Lap Band 2014.;All:sulfa - hives.PCN - SOB;
263 D;bll:+2 meibomitis;rll:frank ect, 7x6mm lid margin bcc lat.a;bul:2mm ptosis;rul:+3 dermato.a
264 bc:+2 inj;bk:med pter;rk:mod endo gut.a;bac:+1 fc, +1 pig cells;
265 bd:+2 bowtie pallor;rcup:0.6Vx0.4H w/ inf notch;lcup:0.5;rmac:+2 BDR, +CSME;lmac:flat, tr BDR;v:+PPDR, ++venous beading;rp:ht 1 o,no vh;
266 scDist;5:8ix 1rht;4:10ix;6:6ix;2:15xt;8:5ix;ccDist;4:5ix;5:ortho;6:ortho</textarea>
269 Get back to working at the speed of your brain.<br /><br /><br />
271 <small>Now imagine documenting this without typing, without a scribe? It is not that far away...</small>
276 <h3 class="ui-accordion-header external">Shorthand Structure</h3>
277 <div id="general" style="text-align:left;">
278 <h4><b>Usage:</b> field:text(.a)(;)</h4>
279 <blockquote class="style2"><i>where: <br /></i>
280 <b>Field</b> is the shorthand term for the clinical field.<br/>
281 <b>text</b> is the complete or shorthand data to enter into this <b>field</b>:
283 <b>field</b> and <b>text</b> are separated by a "<strong>:</strong>" colon.
285 The trailing "<b>.a</b>"
286 is optional and will <b>append</b> the <b>text</b> to the data already in the field, instead of replacing it.<br />
287 The semi-colon "<b>;</b>" is used to divide entries, allowing multiple field entries simultaneously. <br />
288 <small><i>The semi-colon separates entries.</i></small><br />
289 After pressing <b>Enter/Return</b> or <b>Tab</b>, the data are submitted and the form is populated. <br />
294 <div id="accordion_hpi_group" name="accordion_group" class="ui-accordion" style="text-align:left;margin:10;padding:20;">
295 <div name="hpi" class="ui-accordion external">
296 <h3 name="hpi_group" id="hpi_0">History of Present Illness: Shorthand Walk Through</h3>
297 <div name="hpi_group" class="external" style="text-align:left;margin:0;padding:0;">
298 <a name="example_hpi"></a>
299 <blockquote class="style2">
300 <h4 class="underline">Shorthand</h4>
301 <textarea class="kb_entry" style="min-height:1in;">CC:"My eyes are tearing and there is a yellow discharge";hpi:The symptoms began last week and the discharged turned yellow yesterday. No photophobia. The redness spread from the right to the left eye two days ago.;
303 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_hpi.png" style="width: 90%;" alt="Shorthand Example: Anterior Segment">
310 <div id="accordion_pmh_group" name="accordion_group" class="ui-accordion" style="text-align:left;margin:10;padding:20;">
311 <div name="pmh" class="ui-accordion external">
312 <h3 name="pmh_group" id="pmh_0">Past Medical History: Shorthand Walk Through</h3>
313 <div name="pmh_group" class="external" style="text-align:left;margin:0;padding:0;">
314 <a name="example_pmh"></a>
315 <blockquote class="style2">
316 <h4 class="underline">Shorthand</h4>
317 <textarea class="kb_entry" style="height:1in;">POH:POAG. Myopia. Dry Eye; POS:Phaco/IOL OD 4/4/1994.Phaco/IOL OS 4/24/1995.
318 Yag/PCO OD 6/5/1999;Meds:Timolol 0.5% GFS QHS OU. Latanoprost 0.01% QHS OU.
319 Trazadone 50mg PO QHS.Famvir 500mg PO TID;Surg:Appendectomy 1998.
320 Choly 2010.Lap Band 2014.;All:sulfa - hives.PCN - SOB;</textarea>
321 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_pmh.png" style="width: 90%;" alt="Shorthand Example: Anterior Segment">
328 <div id="accordion_external_group" name="accordion_group" class="ui-accordion" style="text-align:left;margin:10;padding:20;">
329 <div name="external" class="ui-accordion external">
330 <h3 name="external_group" id="external_0">External: Shorthand Walk Through</h3>
331 <div name="external_group" class="external" style="text-align:left;margin:0;padding:0;">
332 <a name="example_ext"></a>
333 <blockquote class="style2">
334 <h4 class="underline">Shorthand</h4>
335 <textarea class="kb_entry">D;bll:+2 meibomitis;rll:frank ect, 7x6mm lid margin bcc lat.a;bul:2mm ptosis;rul.+3 dermato.a
337 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_ext.png" style="width: 90%;" alt="Shorthand Example: Anterior Segment">
341 <h3>External: Example Output</h3>
342 <div id="external_output" style="text-align:left;margin:0;padding:0;">
343 <blockquote class="style2">
345 <b>D;bll:+2 meibomitis;rll:frank ect, 7x6mm lid margin bcc lat.a;bul:2mm ptosis;rul.+3 dermato.a</b>
350 <div class="output_EMR" >
352 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_ext_EMR.png" width="95%" alt="Shorthand Example: openEMR">
354 <div class="output_reports">
356 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_ext_report.png" width="75%" alt="Shorthand Example: Reports">
360 <h3>External: Field Codes and Shorthand/Abbreviations</h3>
361 <div id="external_codes" style="clear:both; border:0pt solid black;text-align:left;">
362 <a name="output_external"></a>
363 <blockquote class="style2">
364 <table style="border:0pt solid black;margin:10;">
365 <tr class="style3"><th>Clinical Field</th><th>Shorthand* Field</th><th>Example Shorthand**</th><th>EMR: Field text</th></tr>
367 <td>Default values</td><td>D or d</td>
368 <td><b style="color:red;">d;</b><br /><b style="color:red;">D;</b></td>
369 <td>All fields with defined default values are <b>erased</b> and filled with default values.<br />Fields without defined default values are not affected. </td>
372 <td>Default External values</td><td>DEXT or dext</td>
373 <td><b style="color:red;">dext;</b><br /><b style="color:red;">DEXT;</b></td>
374 <td>All External Exam fields with defined default values are <b>erased</b> and filled with default values.<br />External Fields without defined default values and all other fields on the form are not affected. </td>
377 <td>Right Brow</td><td>rb or RB</td>
378 <td><b style="color:red;">rb</b>:1cm lat ptosis<br /><b style="color:red;">rb</b>:med 2cm SCC</td>
379 <td>1cm lateral ptosis<br />medial 2cm SCC</td>
382 <td>Left Brow</td><td>lb or LB</td>
383 <td><b style="color:red;">lb</b>:loss of lat brow follicles<br /><b style="color:red;">lb</b>:no rhytids from VIIth nerve palsy</td>
384 <td>loss of lateral brow follicles<br />no rhytids from VIIth nerve palsy</td>
387 <td>Both Brows/Forehead</td><td>fh or FH<br />bb or BB</td>
388 <td><b style="color:red;">fh</b>:+3 fh rhytids<br><b style="color:red;">BB</b>:+3 glab rhytids</td>
389 <td>+3 forehead rhytids<br />+3 glabellar rhytids</td>
392 <td>Right Upper Lid</td><td>rul or RUL</td>
393 <td><b style="color:red;">RUL</b>:1cm lat ptosis<br /><b style="color:red;">rul</b>:med 2cm SCC</td>
394 <td>1cm lateral ptosis<br />medial 2cm SCC</td>
397 <td>Left Upper Lid</td><td>lul or LUL</td>
398 <td><b style="color:red;">LUL</b>:1cm lat ptosis<br /><b style="color:red;">lul</b>:med 2cm SCC</td>
399 <td>1cm lateral ptosis<br />medial 2cm SCC</td>
402 <td>Right Lower Lid</td><td>rll or RLL</td>
403 <td><b style="color:red;">rll</b>:1cm lat ptosis<br /><b style="color:red;">rll</b>:med 2cm SCC</td>
404 <td>1cm lateral ptosis<br />medial 2cm SCC</td>
407 <td>Left Lower Lid</td><td>lll or LLL</td>
408 <td><b style="color:red;">lll</b>:0.5cm lat ptosis<br /><b style="color:red;">LLL</b>:med 2cm SCC</td>
409 <td>1cm lateral ptosis<br />medial 2cm SCC</td>
412 <td>Both Lower Lids</td><td>bll or BLL</td>
413 <td><b style="color:red;">lll</b>:0.5cm lat ptosis<br /><b style="color:red;">LLL</b>:med 2cm SCC</td>
414 <td>1cm lateral ptosis<br />medial 2cm SCC</td>
417 <td>All 4 Lids</td><td>4xl or 4XL</td>
418 <td><b style="color:red;">4xl</b>:+2 laxity<br /><b style="color:red;">4xL</b>:+2 dermato</td>
419 <td>+2 laxity<br />+2 dermatochalasis</td>
422 <td>Right Medial Canthus</td><td>rmc or RMC</td>
423 <td><b style="color:red;">rmc</b>:1cm bcc<br /><b style="color:red;">RMC</b>:healed dcr scar</td>
424 <td>1cm BCC<br />healed DCR scar</td>
427 <td>Left Medial Canthus</td><td>lmc or LMC</td>
428 <td><b style="color:red;">lmc</b>:acute dacryo, tender w/ purulent drainage<br /><b style="color:red;">lmc</b>:1.2cm x 8mm mass</td>
429 <td>acute dacryo, tender with purulent drainage<br />1.2cm x 8mm mass</td>
432 <td>Both Medial Canthi</td><td>bmc or BMC</td>
433 <td><b style="color:red;">bmc</b>:chronic dacryo, non-tender<br /><b style="color:red;">BMC</b>:scaling, ulcerated lesion</td>
434 <td>chronic dacryo, non-tender<br />scaling, ulcerated lesion</td>
437 <td>Right Adnexa</td><td>rad or RAD</td>
438 <td><b style="color:red;">rad</b>:1.8x2.0cm bcc lat<br /><b style="color:red;">RAD</b>:healed DCR scar</td>
439 <td>1cm BCC<br />healed DCR scar</td>
443 <td>Left Adnexa</td><td>lad or LAD</td>
444 <td><b style="color:red;">lad</b>:1cm lacr cyst protruding under lid<br /><b style="color:red;">LAD</b>:1.2cm x 8mm mass</td>
445 <td>1cm lacrimal cyst protruding under lid<br />1.2cm x 8mm mass</td>
448 <td>Both Adnexae</td><td>bad or BAD</td>
449 <td><b style="color:red;">bad</b>:lacr gland prolapse<br /><b style="color:red;">BAD</b>:lat orb wall missing</td>
450 <td>lacrimal gland prolapse<br />lateral orbital wall missing</td>
453 <br />*<i>case insensitive</i><br />
454 **<i>The default action is to replace the field with the new text.
456 Adding <b>".a"</b> at the end of a <b>text</b> section will append the current text instead of replacing it.
457 <br >For example, <b>entering "4xL:+2 meibomitis.a" will <u>append</u> "+2 meibomitis"</b>
458 to each of the eyelid fields, RUL/RLL/LUL/LLL.</i>
461 <a name="abbrev_external"></a>
462 <h2 class="underline">External Shorthand Abbreviations:</h2>
464 The following terms will be expanded from their shorthand to full expression in the EMR fields:
466 <table style="border:1pt solid black;margin:10;width:85%;">
467 <tr class="style3"><th>Enter this:</th><th>Get this:</th></tr>
468 <tr><td>inf</td><td>inferior</td></tr>
469 <tr><td>sup</td><td>superior</td></tr>
470 <tr><td>nas</td><td>nasal</td></tr>
471 <tr><td>temp</td><td>temporal</td></tr>
472 <tr><td>med</td><td>medial</td></tr>
473 <tr><td>lat</td><td>lateral</td></tr>
474 <tr><td>dermato</td><td>dematochalasis</td></tr>
475 <tr><td>w/</td><td>with</td></tr>
476 <tr><td>lac</td><td>laceration</td></tr>
477 <tr><td>lacr</td><td>lacrimal</td></tr>
478 <tr><td>dcr</td><td>DCR</td></tr>
479 <tr><td>bcc</td><td>BCC</td></tr>
480 <tr><td>scc</td><td>SCC</td></tr>
481 <tr><td>sebca</td><td>sebaceous cell</td></tr>
482 <tr><td>tr</td><td>trace</td></tr>
489 <div id="accordion_antseg_group" name="accordion_group" class="ui-accordion" style="text-align:left;margin:10;padding:20;">
491 <h3 class="antseg" id="antseg_0" name="antseg_group">Anterior Segment: Shorthand Walk Through</h3>
492 <div id="antseg_input" class="ANTSEG" style="text-align:left;margin:0;padding:0;">
493 <a name="example_antseg"></a>
495 <blockquote class="style2">
496 <h4 class="underline">Shorthand</h4>
497 <textarea class="kb_entry">D;bc:+2 inj;bk:med pter;rk:mod endo gut.a;bac:+1 fc, +1 pig cells
499 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_antseg.png" alt="Shorthand Example: Anterior Segment">
503 <h3>Anterior Segment: Example Output</h3>
504 <div id="external_output" style="text-align:left;margin:0;padding:20;">
505 <blockquote class="style2">
507 <b>D;bc:+2 inj;bk:med pter;rk:mod endo gut.a;bac:+1 fc, +1 pig cells</b><br />
511 <div class="output_EMR well-sm">
513 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_antseg_EMR.png" width="90%" alt="Shorthand Example: openEMR">
515 <div class="output_reports">
517 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_antseg_report.png" width="95%" alt="Shorthand Example: Reports">
521 <h3>Anterior Segment: Field Codes and Shorthand/Abbreviations</h3>
522 <div id="antseg_codes" style="clear:both; border:0pt solid black;text-align:left;">
523 <a name="output_antseg"></a>
524 <blockquote class="style2">
525 <table style="border:0pt solid black;margin:10;padding:10;">
526 <tr class="style3"><th>Clinical Field</th><th>Shorthand* Field</th><th>Example Shorthand**</th><th>EMR: Field text</th></tr>
528 <td>Default values</td><td>D or d</td>
529 <td><span class="field">d</span>;<br /><span class="field">D</span>;</td>
530 <td>All fields with defined default values are <b>erased</b> and filled with default values.<br />Fields without defined default values are not affected. </td>
533 <td>Default Anterior Segment values</td><td>DANTSEG or das</td>
534 <td><b style="color:red;">dantseg;</b><br /><b style="color:red;">DAS;</b></td>
535 <td>All Anterior Segment fields with defined default values are <b>erased</b> and filled with default values.<br />Anterior Segment Fields without defined default values and all other fields on the form are not affected. </td>
538 <td>Conjunctiva</td><td>Right = rc<br />Left = lc<br />Both = bc or c</td>
539 <td><span class="field">rc:</span>+1 inj<br /><span class="field">c:</span>med pter</td>
540 <td>"+1 injection" (right conj only)<br />"medial pterygium" (both right and left fields are filled)</td>
543 <td>Cornea</td><td>Right = rc<br />Left = lc<br />Both = bk or k</td>
544 <td><span class="field">rk:</span>+3 spk<br /><span class="field">k:</span>+2 end gut<b style="color:green">;</b><span class="field">rk:</span>+1 str edema<b style="color:green">.a</b></td>
545 <td>"+3 SPK" (right cornea only)<br />"+2 endothelial guttatae" (both cornea fields) AND "+1 stromal edema" (appended to Right cornea field)</td>
548 <td>Anterior Chamber</td><td>Right = rac<br />Left = lac<br />Both = bac or ac</td>
549 <td><span class="field">rac:</span>+1 fc<br><span class="field">ac:</span>+2 flare</td>
550 <td>"+1 flare/cell" (right A/C field only)<br />"+2 flare" (both A/C fields)</td>
553 <td>Lens</td><td>Right = rl<br />Left = ll<br />Both = bl or l</td>
554 <td><span class="field">RL:</span>+2 NS<br /><span class="field">ll:</span>+2 NS<b style="color:green">;</b><span class="field">l:</span>+3 ant cort spokes.a</td>
555 <td>"+2 NS" (right lens only)<br />"+2 NS" (left lens fields) AND "+3 anterior cortical spokes" (appended to both lenses)</td>
558 <td>Iris</td><td>Right = ri<br />Left = li<br />Both = bi or i</td>
559 <td><b style="color:red">bi.</b>12 0 iridotomy<br /><span class="field">ri:</span>+2 TI defects<b style="color:green">.a</b><b style="color:navy">;</b><span class="field">li</span>.round</td>
560 <td>"12 o'clock iriditomy
" (both iris fields)<br />", +
2 TI defects
" (right iris field) AND "round
" (left iris field only)</td>
563 <td>Gonio</td><td>Right = rg<br />Left = lg<br />Both = bg or g</td>
564 <td><span class="field
">rg:</span>ss 360<br /><span class="field
">lg:</span>3-5 o angle rec</td>
565 <td>SS 360<br />3-5 o'clock angle recession</td>
568 <td>Pachymetry</td><td>Right = rp<br />Left = lp<br />Both = bp or p</td>
569 <td><span class="field
">lp:</span>625 um<br /><span class="field
">p:</span>550 um</td>
570 <td>"625 um
" (left pachymetry field)<br />"500 um
" (both pachymetry fields)</td>
573 <td>Schirmer I</td><td>Right = rsch1<br />Left = lsch1<br />Both = bsch1 or sch1</td>
574 <td><span class="field
">rsch1:</span>5mm<br /><span class="field
">sch1:</span>< 10mm/5 minutes</td>
575 <td>"5mm
" (right field only)<br />"<
; 10mm
/5 minutes
" (both fields)</td>
578 <td>Schirmer II</td><td>Right = rsch2<br />Left = lsch2<br />Both = bsch2 or sch2</td>
579 <td><span class="field
">rsch2:</span>9 mm<br /><span class="field
">sch2:</span>< 10mm/5 minutes</td>
580 <td>"9 mm
" (right field only)<br />"<
; 10mm
/5 minutes
" (both fields)</td>
583 <td>Tear Break-up Time</td><td>Right = RTBUT<br />Left = LTBUT<br />Both = BTBUT or tbut</td>
584 <td><span class="field
">tbut:</span>< 10 seconds<br /><span class="field
">Rtbut:</span>5 secs<b style="color
:green
">;</b><span class="field
">ltbut:</span>9 seconds<b style="color
:green
">;</b></td>
585 <td>"10 seconds
" (both fields)<br />"5 seconds
" (right) AND "9 seconds
" (left)</td>
588 <br />*<i>case insensitive</i><br />
589 **<i>The default action is to replace the field with the new text.
591 Adding <b>".a
"</b> at the end of a <b>text</b> section will append the current text instead of replacing it.
592 <br >For example, entering <b>"bk
:+
2 str scarring
.a
"</b> will <class="underline bold
">append</class> "+
2 stromal scarring
"</b>
593 to both the right (rk) and left cornea fields (lk).</i></small>
597 <a name="abbrev_antseg
"></a>
598 <h2 class="underline
">External Shorthand Abbreviations:</h2>
600 The following terms will be expanded from their shorthand to full expression in the EMR fields:
601 <table style="border
:1pt solid black
;margin
:10;width
:85%
;">
602 <tr class="style3
"><th>Enter this:</th><th>Get this:</th></tr>
603 <tr><td>inf</td><td>inferior</td></tr>
604 <tr><td>sup</td><td>superior</td></tr>
605 <tr><td>nas</td><td>nasal</td></tr>
606 <tr><td>temp</td><td>temporal</td></tr>
607 <tr><td>med</td><td>medial</td></tr>
608 <tr><td>lat</td><td>lateral</td></tr>
609 <tr><td>dermato</td><td>dematochalasis</td></tr>
610 <tr><td>w/</td><td>with</td></tr>
611 <tr><td>lac</td><td>laceration</td></tr>
612 <tr><td>lacr</td><td>lacrimal</td></tr>
613 <tr><td>dcr</td><td>DCR</td></tr>
614 <tr><td>bcc</td><td>BCC</td></tr>
615 <tr><td>scc</td><td>SCC</td></tr>
616 <tr><td>sebca</td><td>sebaceous cell</td></tr>
617 <tr><td>tr</td><td>trace</td></tr>
624 <div id="accordion_retina_group
" name="accordion_group
" class="ui
-accordion
" style="text
-align
:left
;margin
:10;padding
:20;">
626 <h3 class="retina
">Retina: Shorthand Walk Through</h3>
627 <div id="retina_input
" class="RETINA
" style="text
-align
:left
;margin
:0;padding
:0;">
628 <blockquote class="style2
">
629 <h4 class="underline
">Shorthand</h4>
630 <textarea class="kb_entry
">D;bd.+2 bowtie pallor;rcup.0.6Vx0.4H w/ inf notch;lcup.0.5;rmac.+2 BDR, +CSME;lmac.flat, tr BDR;v.+PPDR, ++venous beading;rp.ht 1 o,no vh;
632 <img src="<?php
echo $GLOBALS['webroot']; ?
>/interface/forms
/eye_mag
/images
/sh_retina
.png
" alt="Shorthand Example
: Anterior Segment
">
636 <h3>Retina: Example Output</h3>
637 <div id="retina_output
" style="text
-align
:left
;margin
:0;padding
:20;">
638 <blockquote class="style2
">
640 <b>D;bd:+2 bowtie pallor;rcup:0.6Vx0.4H w/ inf notch;lcup:0.5;rmac:+2 BDR, +CSME;lmac:flat, tr BDR;v:+PPDR, ++venous beading;rp:ht 1 o,no vh;
645 <div class="output_EMR
">
647 <img src="<?php
echo $GLOBALS['webroot']; ?
>/interface/forms
/eye_mag
/images
/sh_retina_EMR
.png
" width="95%
" alt="Shorthand Example
: openEMR
">
649 <div class="output_reports
">
651 <img src="<?php
echo $GLOBALS['webroot']; ?
>/interface/forms
/eye_mag
/images
/sh_retina_report
.png
" width="95%
" alt="Shorthand Example
: Reports
">
655 <h3>Retina: Field Codes and Shorthand/Abbreviations</h3>
656 <div id="retina_codes
" style="clear
:both
; border
:0pt solid black
;text
-align
:left
;">
657 <blockquote class="style2
">
658 <table style="border
:1pt solid black
;margin
:10;width
:85%
;">
659 <tr class="style3
"><th>Clinical Field</th><th>Shorthand* Field</th><th>Example Shorthand**</th><th>EMR: Field text</th></tr>
661 <td>Default values</td><td>D or d</td>
662 <td><span class="field
">d</span>;<br /><span class="field
">D</span>;</td>
663 <td>All fields with defined default values are <b>erased</b> and filled with default values.<br />Fields without defined default values are not affected. </td>
666 <td>Default Retina values</td><td>DRET or dret</td>
667 <td><b style="color
:red
;">dext;</b><br /><b style="color
:red
;">DEXT;</b></td>
668 <td>All Retina/Posterior Segment Exam fields with defined default values are <b>erased</b> and filled with default values.<br />Retinal Fields without defined default values and all other fields on the form are not affected. </td>
672 <td>Right = rd<br />Left = ld<br />Both = bd</td>
673 <td><span class="field
">rd:</span>temp pallor, PPA<br /><span class="field
">bd:</span>NVD at 5 o</td>
674 <td>"temporal pallor
, PPA
" (right disc only)<br />"NVD at
5 o
'clock" (both right and left disc fields)</td>
677 <td>Cup</td><td>Right = rcup<br />Left = lcup<br />Both = bcup or cup</td>
678 <td><span class="field">rcup:</span>0.5 w/ inf notch<br /><span class="field">cup:</span>temp scalloping, 0.5<b style="color:green">.a</b><b style="color:green">;</b></td>
679 <td>"0.5 with inferior notch (right cup only)<br />"temporal scalloping, 0.5" (appended to both cup fields)</td>
682 <td>Macula</td><td>Right = rmac<br />Left = lmac<br />Both = bmac or mac</td>
683 <td><span class="field">rmac:</span>central scar 500um<br><span class="field">mac:</span>soft drusen, - heme.a</td>
684 <td>"central scar 500um" (right macular field only)<br />"soft drusen, - heme" (appended to both macular fields)</td>
687 <td>Vessels</td><td>Right = rv<br />Left = lv<br />Both = bv or v</td>
688 <td><span class="field">RV:</span>1:2, +2 BDR<br /><span class="field">lv:</span>+CSME w/ hard exudate sup to fov (300um)<b style="color:green">;</b><br /><span class="field">v:</span>narrow arterioles, 1:2<b style="color:green">.a;</b></td>
689 <td>"1:2, +2 BDR" (right vessels only)<br />"+CSME with hard exudate superior to fovea (300um)" (left vessel field only)<br />"narrow arterioles, 1:2" (appended to both vessel fields)</td>
692 <td>Periphery</td><td>Right = rp<br />Left = lp<br />Both = bp or p</td>
693 <td><span class="field">rp:</span>12 0 ht, no heme, amenable to bubble<b style="color:green">;</b><br /><b style="color:red">bp.</b>1 clock hour of lattice 2 o<b style="color:green">.a</b><b style="color:navy">;</b></td>
694 <td>"12 o'clock horseshoe tear
, no heme
, amenable to bubble
" (right periphery field)<br />"1 clock hour of lattice
2 o
'clock" (appended to both periphery fields)</td>
697 <td>Central Macular Thickness</td><td>Right = rcmt<br />Left = lcmt<br />Both = bcmt or cmt</td>
698 <td><span class="field">rcmt:</span>254<br /><span class="field">cmt:</span>flat</td>
699 <td>254 (right CMT only)<br />flat (both CMT fields)</td>
702 <br />*<i>case insensitive</i><br />
703 **<i>The default action is to replace the field with the new text.
705 Adding <b>".a"</b> at the end of a <b>text</b> section will append the current text instead of replacing it.
706 <br >For example, entering <b>"bcup:0.5 w/ inf notch.a"</b> will <class="underline bold">append</class> "0.5 with inferior notch"</b>
707 to both the right (rcup) and left cup fields (lcup).</i></small>
711 <a name="abbrev_retina"></a>
712 <h2 class="underline">Retina Shorthand Abbreviations:</h2>
714 The following terms will be expanded from their shorthand to full expression in the EMR fields:
716 <table style="border:1pt solid black;margin:10;width:85%;">
717 <tr class="style3"><th>Enter this:</th><th>Get this:</th></tr>
718 <tr><td>inf</td><td>inferior</td></tr>
719 <tr><td>sup</td><td>superior</td></tr>
720 <tr><td>nas</td><td>nasal</td></tr>
721 <tr><td>temp</td><td>temporal</td></tr>
722 <tr><td>med</td><td>medial</td></tr>
723 <tr><td>lat</td><td>lateral</td></tr>
724 <tr><td>csme</td><td>CSME</td></tr>
725 <tr><td>w/</td><td>with</td></tr>
726 <tr><td>bdr</td><td>BDR</td></tr>
727 <tr><td>ppdr</td><td>PPDR</td></tr>
728 <tr><td>ht</td><td>horsheshoe tear</td></tr>
729 <tr><td>ab</td><td>air bubble</td></tr>
730 <tr><td>c3f8</td><td>C3F8</td></tr>
731 <tr><td>ma</td><td>macroaneurysm</td></tr>
732 <tr><td>tr</td><td>trace</td></tr>
733 <tr><td>mias</td><td>microaneurysm</td></tr>
734 <tr><td>ped</td><td>PED</td></tr>
735 <tr><td>1 o</td><td> 1 o'clock
</td
></tr
>
736 <tr
><td
>2 o
</td
><td
>2 o
'clock</td></tr>
737 <tr><td>3 o</td><td> 3 o'clock
</td
></tr
>
738 <tr
><td
>4 o
</td
><td
> 4 o
'clock</td></tr>
739 <tr><td>5 o</td><td> 5 o'clock
</td
></tr
>
740 <tr
><td
>6 o
</td
><td
> 6 o
'clock</td></tr>
741 <tr><td>7 o</td><td> 7 o'clock
</td
></tr
>
742 <tr
><td
>8 o
</td
><td
> 8 o
'clock</td></tr>
743 <tr><td>9 o</td><td> 9 o'clock
</td
></tr
>
744 <tr
><td
>10 o
</td
><td
> 10 o
'clock</td></tr>
745 <tr><td>11 o</td><td> 11 o'clock
</td
></tr
>
746 <tr
><td
>12 o
</td
><td
> 12 o
'clock</td></tr>
747 <tr><td>mac</td><td>macula</td></tr>
748 <tr><td>fov</td><td>fovea</td></tr>
749 <tr><td>vh</td><td>vitreous hemorrhage</td></tr>
756 <div id="accordion_neuro_group" name="accordion_group" class="ui-accordion" style="text-align:left;margin:10;padding:20;">
758 <h3 class="neuro">Neuro: Shorthand Walk Through</h3>
759 <div id="neuro_input" class="neuro" style="text-align:left;margin:0;padding:0;">
760 <blockquote class="style2">
761 <h4 class="underline">Shorthand</h4>
762 <textarea class="kb_entry">scDist;5:8ix 1rht;4:10ix;6:6ix;2:15xt;8:5ix;ccDist;4:5ix;5:ortho;6:ortho;
764 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_neuro.png" alt="Shorthand Example: Anterior Segment">
768 <h3>Neuro: Example Output</h3>
769 <div id="neuro_output" style="text-align:left;margin:0;padding:20;">
770 <a name="output_neuro"></a>
771 <blockquote class="style2">
773 <b>scDist;5:8ix 1rht;4:10ix;6:6ix;2:15xt;8:5ix;ccDist;4:5ix;5:ortho;6:ortho;</b><br />
777 <div class="output_EMR">
779 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_neuro_EMR1.png" style="height: 200;width:45%;margin:12 0 0 20;padding-left:10" alt="Shorthand Example: openEMR">
780 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_neuro_EMR2.png" style="float:right;height: 200;width:45%;margin:10 0 0 20;padding-left:10" alt="Shorthand Example: openEMR">
782 <div class="output_reports">
784 <img src="<?php echo $GLOBALS['webroot
']; ?>/interface/forms/eye_mag/images/sh_neuro_report.png" width="75%" alt="Shorthand Example: Reports">
788 <h3>Neuro: Field Codes and Shorthand/Abbreviations</h3>
789 <div id="neuro_codes" style="clear:both; border:0pt solid black;text-align:left;">
790 <blockquote class="style2">
791 <table style="border:1pt solid black;margin:10;width:85%;">
792 <tr class="style3"><th>Clinical Field</th><th>Shorthand* Field</th><th>Example Shorthand**</th><th>EMR: Field text</th></tr>
794 <td>Default values</td><td>D or d</td>
795 <td><span class="field">d</span>;<br /><span class="field">D</span>;</td>
796 <td>All fields with defined default values are <b>erased</b> and filled with default values.<br />Fields without defined default values are not affected. </td>
799 <td>Without correction at Distance</td><td>scDist</td>
800 <td><b style="color:red;">scdist</b><b style="color:green;">;</a></td>
801 <td>scDIST is selected for ensuing values.</td>
804 <td>With correction at Distance</td><td>scDist</td>
805 <td><b style="color:red;">ccdist</b><b style="color:green;">;</a></td>
806 <td>ccDIST is selected for ensuing values.</td>
808 <td>Without correction at Near</td><td>scNear</td>
809 <td><b style="color:red;">scdist</b><b style="color:green;">;</a></td>
810 <td>scDIST is selected for ensuing values.</td>
813 <td>With correction at Near</td><td>scNear</td>
814 <td><b style="color:red;">scdist</b><b style="color:green;">;</a></td>
815 <td>scDIST is selected for ensuing values.</td>
818 <br />*<i>case insensitive</i><br />
819 **<i>The default action is to replace the field with the new text.
821 Adding <b>".a"</b> at the end of a <b>text</b> section will append the current text instead of replacing it.
822 <br >For example, entering <b>"4:5ix.a"</b> will <class="underline bold">append</class> "5 X(T)"</b>
823 to any measurements previously entered into the right gaze field.</i></small>
827 <a name="abbrev_neuro"></a>
828 <h2 class="underline">Neuro Shorthand Abbreviations:</h2>
830 The following terms will be expanded from their shorthand to full expression in the EMR fields:
832 <table style="border:1pt solid black;margin:10;width:85%;">
833 <tr class="style3"><th>Strabismus</th><th>Enter this:</th><th>Get this:</th></tr>
834 <tr><td>Exophoria</td><td>x</td><td>X</td></tr>
835 <tr><td>Intermittent Esotropia</td><td>ie or e(t)</td><td>E(T)</td></tr>
836 <tr><td>Esoptropia</td><td>et</td><td>ET</td></tr>
837 <tr><td>Esophoria</td><td>e</td><td>E</td></tr>
838 <tr><td>Intermittent Exotropia</td><td>ix or x(t)</td><td>X(T)</td></tr>
839 <tr><td>Exoptropia</td><td>xt</td><td>XT</td></tr>
840 <tr><td>Hyperphoria</td><td>h</td><td>H</td></tr>
841 <tr><td>Intermittent Hypertropia</td><td>H(T)</td><td>H(T)</td></tr>
842 <tr><td>Hypertropia</td><td>rht<br />lht</td><td>RHT<br />LHT</td></tr>
843 <tr><td>Hypotropia</td><td>hyt</td><td>HyT</td></tr>