CCHS PHYSICIAN DOCUMENTATION PROJECT
MACROS – Progress Notes
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normal standard content with patient specific findings.
CCHS_GLOBAL
MACROS BY INDIVIDUAL SYSTEMS
General Macro
GENERAL: awake, no acute distress
HEENT Macro
HEAD: normocephalic
EYES/EARS/NOSE THROAT: pupils equal, normal pharynx
Neck Macro
NECK: no lymphadenopathy, no masses
Lung Macro
RESPIRATORY: no respiratory distress, clear to auscultation bilaterally
Heart Macro
CARDIOVASCULAR: regular rate and rhythm, no murmurs, rubs or gallops
Abdomen Macro
ABDOMEN: soft, non-tender, non-distended, normoactive bowel sounds
Extremity Macro
EXTREMITIES: no wounds, no edema
Musculoskeletal Macro
MUSCULOSKELETAL: normal range of motion, no deformity
Neuro Macro
NEUROLOGIC: alert and oriented x 3, no gross motor or sensory deficits
Psych Macro:
PSYCHIATRIC: alert and oriented x 3, normal/depressed/hostile mood and affect, not
currently suicidal or homicidal, cooperative and communicating, no active auditory or visual
hallucinations
Skin Macro
SKIN: no rashes
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MACROS BY INDIVIDUAL SYSTEMS
Breast Exam Macro
BREAST: [ ]
Pulse Exam Macro
PULSES:
LEFT
Radial: []
Carotid: []
Posterior Tibial: []
Dorsalis Pedis: []
RIGHT
Radial: []
Carotid: []
Posterior Tibial: []
Dorsalis Pedis: []
Wound Exam Macro
INCISION/WOUND: [Location]: [appropriate healing], [no erythema], [no induration], [no
drainage]
Rectal Exam Macro:
RECTAL: [non-tender], [stool normal color], [no gross bleeding present], [negative stool
guaiac with quality check], [normal prostate], [no internal or external hemorrhoids, fissures or
masses]
Male GU Exam Macro:
GENITOURINARY: [no testicular or scrotal tenderness, swelling, masses], [no hernias], [no
urethral discharge]
Pelvic Exam Macro:
PELVIC EXAM: [normal external inspection]
SPECULUM EXAM: [no vaginal discharge], [no active bleeding], [no blood clots in vaginal
vault], [os closed and no tissue present]
BIMANUAL EXAM: [no cervical motion tenderness], [no adnexal tenderness], [no masses]
Chaperone was present during the pelvic exam: [Nurse/Other]
Ophtho Exam Macro:
OPHTHALMOLOGIC: Visual acuity: R 20/[20], L 20/[20], [no evidence of globe rupture], [no
eyelid foreign bodies], [no scleral injection, exudates, subconjunctival hemorrhage], [no corneal
abrasions], [no hyphema], [no papilledema], [normal funduscopic exam]
Tonometry: R [ ], L [ ]
Fluorescein exam: R [no abrasions, no ulcers], L [no abrasions, no ulcers]
Slit lamp exam: [normal anterior chamber]
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OTHER MACROS-COMBINATIONS
Heart Lung Macro
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
Heart Lung Abdomen Macro
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender], [non-distended], [normoactive bowel sounds]
ATTENDING TEACHING/ATTESTATION STATEMENTS
Attending Agree Macro
I performed a history and physical exam of the patient and discussed the case with the
resident. I reviewed the resident’s note and agree with the documented findings and plan of
care.
Attending Present Macro
I was present with the resident during the history and exam. I discussed the case with the
resident and agree with the findings and plan as documented in the resident’s note.
Attending Agree Except Macro
I saw and evaluated the patient. I reviewed the resident’s note and agree, except for the
following: [ ]
Attending Reviewed Macro
I saw and evaluated the patient. I reviewed the resident’s note and agree.
Attending Split Macro
Split/shared visit with Physician Assistant and/or Nurse Practitioner
Attending Procedure Entire Macro
Attending Physician Procedure Attestation:
I was present for and personally supervised the entire procedure.
Attending Procedure Key Portion
Attending Physician Procedure Attestation:
I was present for and personally supervised the critical portions of the procedure.
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