CCHS PHYSICIAN DOCUMENTATION PROJECT
MACROS – Progress Notes
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MEDICINE
GENERAL MEDICINE
MEDICINE PROGRESS MACRO:
GENERAL: [no acute distress]
HEAD: [normocephalic]
EYES/EARS/NOSE/THROAT: [pupils are equal, normal oropharynx]
NECK: [normal inspection]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender]
EXTREMITIES: [no wounds, no edema]
NEUROLOGIC: [alert and oriented x 3], [no gross motor or sensory deficits]
MEDICINE BRIEF PROGRESS MACRO:
GENERAL: [no acute distress]
HEAD: [normocephalic]
EYES/EARS/NOSE/THROAT: [pupils are equal, normal oropharynx]
NECK: [normal inspection]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender]
EXTREMITIES: [no wounds, no edema]
NEUROLOGIC: [alert and oriented x 3], [no gross motor or sensory deficits]
MEDICINE EXAM MACRO:
GENERAL: [awake], [well-developed, well-nourished], [comfortable]
HEAD/EYES: [normocephalic, atraumatic], [normal lids and conjunctiva], [pupils equal],
[extraocular muscles intact]
EARS/NOSE/THROAT: [normal external ears/nose], [normal tympanic membranes], [normal
oropharynx]
NECK: [supple], [full range of motion], [no masses], [no thyromegaly]
CARDIOVASCULAR: [normal S1/S2], [regular rate and rhythm], [no murmur/gallop/rub]
RESPIRATORY: [normal effort], [lungs clear to auscultation bilaterally], [no
wheezes/crackles/rhonchi]
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GASTROINTESTINAL: [soft], [non-tender, non-distended], [no hepatosplenomegaly],
[normoactive bowel sounds]
MUSCULOSKELETAL: [normal tone], [normal range of motion], [no clubbing/cyanosis/edema]
SKIN: [no rashes], [no lesions], [no induration], [no nodules]
NEUROLOGIC: [cranial nerves II-XII intact], [deep tendon reflexes 2+ bilaterally], [no tremor],
[sensation intact to light touch and proprioception], [strength 5/5], [normal gait]
PSYCHIATRIC: [alert and oriented x 3], [normal mood and affect], [good judgment]
LYMPHATIC: [no lymphadenopathy]
CARDIOLOGY
CARDIOLOGY PROGRESS MACRO:
GENERAL: [alert, no acute distress]
NECK: [normal inspection], [no JVD]
CARDIOVASCULAR: [regular rate and rhythm], [Normal S1,S2], [no murmurs, rubs or gallops]
RESPIRATORY: [no respiratory distress], [clear to auscultation bilaterally], [no crackles], [no
wheezes]
EXTREMITIES: [non-tender, full ROM, no edema/swelling], [2+ peripheral pulses]
Telemetry reviewed: [no significant events]
CARDIOLOGY EXAM MACRO:
GENERAL: [no acute distress]
HEAD/EYES/EARS/NOSE/THROAT: [normal pharynx], [no scleral icterus], [mucous
membranes moist]
NECK: [normal inspection], [no JVD]
RESPIRATORY: [no respiratory distress], [clear to auscultation bilaterally], [no crackles], [no
wheezes]
CARDIOVASCULAR: [regular rate and rhythm], [Normal S1,S2], [no murmurs, rubs or gallops]
GASTROINTESTINAL: [soft, non-tender, no organomegaly, no masses, normal bowel sounds,
no rebound, no guarding]
EXTREMITIES: [non-tender, full ROM, no edema/swelling], [2+ peripheral pulses]
NEUROLOGIC: [no gross motor or sensory deficits]
SKIN: [warm and dry]
EKG MACRO <rate>: (e.g. EKG Macro 89)
12-lead EKG (interpreted by me): [Normal sinus rhythm], rate = 89, [normal intervals], [normal
QRS duration], [normal axis], [no ST-T wave changes]
Normal EKG MACRO:
12 lead EKG: normal sinus rhythm, normal EKG
Tele MACRO:
Telemetry reviewed: no significant events.
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CHF
CHF PROGRESS MACRO
GENERAL: [alert, no acute distress]
NECK: [normal inspection], [no JVD]
CARDIOVASCULAR: [regular rate and rhythm], [Normal S1,S2], [no murmurs, rubs or gallops]
RESPIRATORY: [no respiratory distress], [clear to auscultation bilaterally], [no crackles], [no
wheezes]
EXTREMITIES: [non-tender, full ROM, no edema/swelling], [2+ peripheral pulses]
Telemetry reviewed: [no significant events]
CHF ATTESTATION
I have seen and examined the Patient. I agree with the documented findings, physical
examination and plan of care as written by the Fellow/Resident in the note.
I spent [_] minutes on the unit with the patient, and 50% of that time was spent in counseling
and coordination of care.
GI
GI PROGRESS MACRO:
GENERAL: [alert, cooperative, no acute distress, comfortable]
CHEST: [clear to auscultation bilaterally, normal breath sounds, normal respiratory effort]
HEART: [regular rate and rhythm, no murmurs, rubs, gallops, normal S1/S2]
ABD: [normal active bowel sounds], [non tender, non distended, no rebound or guarding, no
palpable masses, no hernias, no hepatosplenomegaly]
EXTREMETIES: [no edema or calf tenderness]
GI EXAM MACRO:
GENERAL: [no acute distress]
HEAD: [normocephalic]
EYES/EARS/NOSE/THROAT: [PERRL, EOMI, no scleral icterus, mucous membranes moist]
NECK: [normal inspection]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
GASTROINTESTINAL: [soft, non-tender, no organomegaly, no masses, normal bowel sounds,
no rebound, no guarding]
EXTREMITIES: [non-tender, full ROM, no edema/swelling]
NEUROLOGIC: [alert and oriented X 3], [no gross motor or sensory deficits], [no asterixis]
SKIN: [no rashes], [no jaundice]
GI AGREE MACRO:
The patient was seen and examined by me and powerchart was reviewed, I agree with the
above note as outlined by our physician assistant.
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GI DISCUSS MACRO:
I have discussed my assessment and recommendations with the patient's care team and
the patient, and I have answered all related questions.
GI RISKS BENEFITS MACRO:
I have discussed the potential risks and benefits of the procedure(s) with the patient, and I
have answered all related questions. The patient agrees to proceed the procedure(s) as the
next step in the gastrointestinal evaluation.
HEME ONC
HEME ONC PROGRESS MACRO:
GENERAL: [no acute distress]
EYES/EARS/NOSE/THROAT: [pupils are equal], [normal oropharynx]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender], [no hepatosplenomegaly], [normal bowel sounds]
LYMPHATICS: [no cervical, supraclavicular, axillary or inguinal adenopathy]
EXTREMITIES: [no edema]
SKIN: [no ecchymosis, petechiae, rashes, wounds]
HEME ONC EXAM MACRO:
GENERAL: [no acute distress]
HEAD: [normocephalic]
NECK: [no cervical adenopathy, no supraclavicular adenopathy]
EYES/EARS/NOSE/THROAT: [pupils are equal], [normal oropharynx], [no pallor]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender], [no hepatosplenomegaly], [normal bowel sounds]
GU: [no inguinal adenopathy]
EXTREMITIES: [no wounds], [no edema], [no axillary adenopathy]
NEUROLOGIC: [alert and oriented x 3], [no gross motor or sensory deficits]
SKIN: [warm and dry], [no ecchymosis, petechiae, rashes]
ID
ID PROGRESS MACRO:
APPEARANCE: [stable], [no acute distress]
PULMONARY SYSTEM: [clear to auscultation bilaterally], [no prolongation of expiratory
phase]
CARDIOVASCULAR SYSTEM: [regular rate and rhythm], [no murmurs]
GASTROINTESTINAL SYSTEM: [soft], [non-tender], [no organomegaly], [normal bowel
sounds]
EXTREMITIES: [no edema], [normal temperature]
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ID EXAM MACRO:
APPEARANCE: [stable], [no acute distress]
EYES: [no conjunctival lesions], [no pallor], [non-icteric]
EARS/NOSE/THROAT: [moist mucous membranes], [no lesions]
NECK: [not rigid], [no hepatojugular reflux], [no thyroid enlargement]
INTEGUMENTARY SYSTEM: [normal turgor], [no rash]
PULMONARY SYSTEM: [clear to auscultation bilaterally], [no prolongation of expiratory
phase]
CARDIOVASCULAR SYSTEM: [regular rate and rhythm], [no murmurs]
GASTROINTESTINAL SYSTEM: [soft], [non-tender], [no organomegaly], [normal bowel
sounds]
EXTREMITIES: [no edema], [normal temperature]
LYMPHATIC SYSTEM: [no anterior, posterior triangle, submandibular, or submental
adenopathy], [normal in all lymph node areas palpated]
NEUROLOGIC SYSTEM: [normal motor function and cranial nerves], [normal mental status]
NEUROLOGY
NEUROLOGY PROGRESS MACRO:
GENERAL: [no acute distress]
HEAD: [normocephalic]
EYES/EARS/NOSE/THROAT: [pupils are equal, normal oropharynx]
NECK: [normal inspection]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender]
EXTREMITIES: [no wounds, no edema]
NEUROLOGIC: [cranial nerves II-XII intact], [deep tendon reflexes 2+ bilaterally], [no tremor],
[sensation intact to light touch and proprioception], [strengths 5/5 in all extremities], [normal
gait]
PSYCHIATRIC: [alert and oriented x 3], [normal mood and affect], [good judgment]
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PAIN & PALLIATIVE
PAIN SERVICE SUBJECTIVE MACRO
Chief Complaint: [ ]
Interval HPI: [ ]
Current Symptoms (0 – none, 1 – mild, 2 – moderate, 3 – severe)
Depression: [ ]
Agitation:
[ ]
Nausea:
[ ]
Anorexia:
[ ]
Inactivity:
[ ]
Anxiety:
[ ]
Constipation: [ ]
Physical Discomfort: [ ]
Dyspnea:
[ ]
Drowsiness: [ ]
Describe moderate to severe symptoms: [ ]
Pain score (0 – 10):
Neuropathic: [ ]
Dementia: [ ]
Nociceptive: [ ]
Delirium: [ ]
Acute: [ ]
Coma: [ ]
Chronic: [ ]
Hyperalgesia: [ ]
Kamofsky: [ ]%
REVIEW OF SYSTEMS:
[ ]
PAIN SERVICE EXAM MACRO
CONSTITUTIONAL: [awake, well-developed, well-nourished, comfortable]
HEAD/EYES: [normocephalic, atraumatic], [normal lids and conjunctiva, pupils equal and
reactive to light and accommodation, extraocular muscles intact]
EARS/NOSE/THROAT: [normal external ears/nose], [normal tympanic membranes], [normal
oropharynx]
NECK: [supple, full range of motion, no masses, no thyromegaly]
CARDIOVASCULAR: [normal S1 and S2, regular rate and rhythm, no murmurs / rubs /
gallops]
RESPIRATORY: [normal effort, lungs clear to auscultation bilaterally, no wheezing / crackles /
rhonchi]
GASTROINTESTINAL: [soft, non-tender, non-distended, no hepatosplenomegaly, normoactive
bowel sounds]
MUSCULOSKELETAL: [normal tone, normal range of motion, no clubbing / cyanosis / edema]
SKIN: [no rashes, no lesions, no induration, no nodules]
NEUROLOGIC: [cranial nerves II-XII intact, deep tendon reflexes 2+ bilaterally, no tremor,
sensation intact to light touch and proprioception, strengths 5/5, normal gait]
PSYCHIATRIC: [alert and oriented x 3, normal mood and affect, good judgment]
LYMPHATICS: [no lymphadenopathy]
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PAIN SERVICE PLAN MACRO
Reviewed medical condition with: [patient / staff / family]
[
[
[
[
[
[
[
[
] Treatments initiated or adjusted
] Patient and family education
] Prognosis addressed
] Goals of care addressed
] Transition planning discussed
] Spiritual counseling/support
] Psychosocial support
] Discharge planning]
Code status:
[ ]
Length of visit: [ ] minutes, [>50%] of time spent counseling and/or coordination of care
Additional Medical Decision Making, Diagnoses, Assessment/Plan and Family Discussion:
[ ]
PULMONARY
PULMONARY PROGRESS MACRO:
GENERAL: [no acute distress]
HEAD: [normocephalic]
EYES/EARS/NOSE/THROAT: [pupils are equal, normal oropharynx]
NECK: [normal inspection]
RESPIRATORY: [no respiratory distress], [clear to auscultation bilaterally, no
wheezing/crackles/rhonchi]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender]
EXTREMITIES: [no wounds, no edema]
NEUROLOGIC: [alert and oriented x 3], [no gross motor or sensory deficits]
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PSYCHIATRY
PSYCH PROGRESS MACRO
GENERAL: [well developed/well nourished, [no distress]
INTERACTIONS: [cooperative, polite, attentive]
PSYCHOMOTOR: [normal psychomotor activity], [no tremors]
GAIT AND STATION: [no ataxia], [steady gait]
SPEECH: [normal volume, articulate, coherent, spontaneous, normal rate]
THOUGHT PROCESS: [logical, goal oriented, no increase or decrease in rate]
ASSOCIATIONS: [intact, not loose, tangential or circumstantial]
MOOD: [calm]
AFFECT: [full range, appropriate]
DANGEROUSNESS: [no suicidal or self-injurious: indication/ideation/intent/plan], [no violent
ideations/intent/plan]
THOUGHT CONTENT: [no hallucinations], [no delusions], [no obsessions/compulsions], [no
panic], [no phobias], [no flashbacks/nightmares], [no somatic preoccupations], [no excess
worry]
LEVEL OF CONSCIOUSNESS: [alert]
ORIENTATION: [intact to time, place, person and situation], [no disorientation]
LANGUAGE: [able to repeat phrases], [able to name objects]
MEMORY: [intact to immediate, recent and remote]
FUND OF KNOWLEDGE: [adequate (aware of current events; past history; vocabulary)]
ABSTRACT REASONING: [intact, concrete]
ATTENTION/CONCENTRATION: [intact]
COMPUTATION: [intact]
JUDGEMENT: [intact]
INSIGHT: [intact]
ADDITIONAL FINDINGS: [ ]
MED PSYCH PROGRESS MACRO
GENERAL: [no acute distress]
HEAD: [normocephalic]
EYES/EARS/NOSE/THROAT: [pupils are equal, normal oropharynx]
NECK: [normal inspection]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN: [soft, non-tender]
EXTREMITIES: [no wounds], [no edema]
NEUROLOGIC: [no gross motor or sensory deficits]
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]
MED PSYCH EXAM MACRO
GENERAL: [no acute distress]
HEAD: [normocephalic]
EYES/EARS/NOSE/THROAT: [pupils equal, extraocular muscles intact, no scleral icterus,
normal pharynx]
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NECK: [normal inspection]
RESPIRATORY: [no respiratory distress, clear to auscultation bilaterally]
CARDIOVASCULAR: [regular rate and rhythm, no murmurs, rubs or gallops]
ABDOMEN/GU: [soft, non-tender, no organomegaly, no masses, normal bowel sounds]
EXTREMITIES: [non-tender, normal range of motion, no edema/swelling]
NEUROLOGIC: [alert and oriented x 3, no gross motor deficits, no gross sensory deficits,
cranial nerves intact]
PSYCH: [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: [no rashes]
Restraints: [none]
PSYCH PROGRESS MACRO
GENERAL: [well developed/well nourished, [no distress]
INTERACTIONS: [cooperative, polite, attentive]
PSYCHOMOTOR: [normal psychomotor activity], [no tremors]
GAIT AND STATION: [no ataxia], [steady gait]
SPEECH: [normal volume, articulate, coherent, spontaneous, normal rate]
THOUGHT PROCESS: [logical, goal oriented, no increase or decrease in rate]
ASSOCIATIONS: [intact, not loose, tangential or circumstantial]
MOOD: [calm]
AFFECT: [full range, appropriate]
DANGEROUSNESS: [no suicidal or self-injurious: indication/ideation/intent/plan], [no violent
ideations/intent/plan]
THOUGHT CONTENT: [no hallucinations], [no delusions], [no obsessions/compulsions], [no
panic], [no phobias], [no flashbacks/nightmares], [no somatic preoccupations], [no excess
worry]
LEVEL OF CONSCIOUSNESS: [alert]
ORIENTATION: [intact to time, place, person and situation], [no disorientation]
LANGUAGE: [able to repeat phrases], [able to name objects]
MEMORY: [intact to immediate, recent and remote]
FUND OF KNOWLEDGE: [adequate (aware of current events; past history; vocabulary)]
ABSTRACT REASONING: [intact, concrete]
ATTENTION/CONCENTRATION: [intact]
COMPUTATION: [intact]
JUDGEMENT: [intact]
INSIGHT: [intact]
ADDITIONAL FINDINGS: [ ]
PSYCH MENTAL STATUS EXAM MACRO
GENERAL
Appearance: [meticulous, neat/casual, careless, disorderly]
Cooperation: [Suggestible, passively cooperative, cooperative, passive]
Eye contact: [normal, decreased, increase]
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Sociality: [gregarious, friendly, aloof, seclusive]
Manner: [spontaneous, anxious, irritable, agitated, guarded, suspicious]
Motor Activity: [normal, hyperactive, decreased, deliberate, aimless, destructive, rigid
mannerisms, self-exposure, assaultive, abnormal movements]
SPEECH
Form: [coherent, circumstantial, tangential, looseness of association, flight of ideas,
incoherent, slurred, echolalia, clanging, word salad, evasive]
Content: [relevant, distractible, confabulation, irrelevant, neologisms, profanity]
Productivity: [normal, pressured, spontaneous, repetitive, blocked, mute]
AFFECTIVE STATUS
Range: [normal, labile, constricted, blunted, flat, appropriate to ideation, inappropriate to
ideation]
Mood: [depersonalization, derealization]
Affect: [normal, manic, elated, indifferent, depressed, anxious]
CONTENT OF THOUGHT
Preoccupation: [absent, obsessions, compulsions, phobias, ruminations, guilt]
Death Wish: [toward self, toward others, passive, active, absent]
Delusions: [absent, influence, reference, somatic, paranoid, grandiose, nihilistic, religious]
Hallucinations/Illusions: [absent, auditory, olfactory, tactile, gustatory]
COGNITIVE STATUS
Level of consciousness: [alert, drowsy, stupor]
Orientation: [Oriented, disoriented to person/place/time]
Attention: [intact, decreased]
Concentration: [adequate, inadequate]
Memory: [intact, defect in recent/remote]
Intelligence: [superior, above/below average, average, retarded]
JUDGEMENTS AND INSIGHT
Common sense: [good/fair/poor]
Impulse control: [good/fair/poor]
Judgment in regard to chief complaint: [good/fair/poor]
Intellectual insight: [good/fair/poor]
Emotional insight: [good/fair/poor]
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REVIEW OF SYSTEMS
ROS as per HPI MACRO:
A 10 system review of systems was completed and negative except as documented in HPI.
ROS as above MACRO:
[ROS]
A 10 system review of systems was completed and negative except as documented above.
ROS MACRO:
Constitutional: [no fever/chills, no diaphoresis, no weakness, no recent illness]
Eyes/ENT: [no vision problems, no sore throat]
Cardiovascular: [no chest pain, no palpitations]
Respiratory: [no shortness of breath], [no cough]
GI/GU: [no abdominal pain, no nausea, no vomiting, no diarrhea, no black stools, no problems
urinating]
Musculoskeletal/Skin/Lymph: [no myalgias, no arthralgias, no rashes, no gland swelling]
Neuro/Psych: [no headache, no dizziness, no difficulty walking, no anxiety/depression]
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