Auto-fill templates

 

 

.auto = list of auto-fills

.an = antenatal care

Antenatal Care

Billing = F2F: 16500 / V: 91853 / P: 91858

.bi = Billing

Billing:

.covax = COVID-19 vaccine suitability

COVID-19 vaccine suitability

Billing: 93644

.ecg = ECG

ECG:

Billing: 11707

.fh = Family history

Family History:

.iron = Iron infusion protocol

Presents for Iron Infusion

Referred by =

Haemoglobin =

Iron =

Ferritin =

Symptoms =

Indications (e.g. Imminent surgery, rapid iron depletion, lack of efficacy or tolerance or compliance of oral iron, malabsorption, CKD, CHF) =

Contraindications (e.g. anaemia due to other causes, iron overload, known hypersensitivity, patient age <14, first trimester pregnancy) =

Precautions (e.g. significant liver dysfunction, acute or chronic infection, asthma or atopic allergies, pregnancy, risk of paravenous leak, chronic inflammatory states, risks with hypophosphataemia) =

Risks discussed

Common (Less than 10%) = Headache, dizziness, flushing, nausea, site reactions, hypophosphataemia

Uncommon (Less than 1%) = Skin staining, numbness, tingling, taste change, fast heart rate, short of breath, fever

Rare (Less than 0.1%) = Malaise, vertigo, syncope, anxiety, angioedema

Very rare = Anaphylaxis at 1 in 250,000

IVC inserted

Arm =

Gauge =

10mL normal saline flushed without pain or resistance

Iron given via slow IVI. Ferinject dose =

Monitored post infusion

Side effects =

Advised to seek help if any concerns

Follow up with original referrer or GP in 4 to 6 weeks

Patient leaflet given

.mh = Mental Health

Mental Health

Billing: F2F: 2713 V: 92115 P: 92127

F2F: 2712 V: 92114 P: 92126

F2F: 2715 V: 92116

F2F: 2717 V: 92117

.pc = Presenting complaint

Presenting Issue:

History:

Exam:

Plan:

Review:

Billing:

.rv = review

Review:

.soap = subjective, objective, assessment, plan

Subjective:

Objective:

Assessment:

Plan:

Bill:

Review:

.smoke = smoking cessation

Smoking cessation:

Years smoked =

Per day =

Reasons to quit = $12k per year, 10+ year of life

Barriers =

Enablers =

Options discussed

- Behavioural coping strategies

- Quitline 137848

- NRT long and short-acting

- Champix / Zyban

Plan:

Billing = F2F 93680 Telehealth 93690 Telephone 93700 or 20 min+ = F2F: 93683 / Telehealth: 93693 / Telephone: 93703

.sex = sexual or reproductive health

Sexual or Reproductive Health

Billing: V: 92715 / P: 92731 = < 5 min

V: 92718 / P: 92734 = 5 - 20 min

V: 92721 / P: 92737 = 20 - 40 min

V: 92724 / P: 92740 = > 40 min

.ti = time

Time:

.ua = urinalysis

Urinalysis:

Leukocytes =

Nitrites =

Blood =

Protein =

Glucose =

Ketones =

pH =

Urobilinogen =

SG =

Bilirubin =

.ub = urine BHCG

Urine BHCG

Result =

Billing = 73806

.urti