Epic SmartPhrases

If you do not use the electronic medical record Epic Hyperspace, this article is probably of no interest to you.

I previously wrote that I have done a lot of customizations to Epic. In this post I’ll explain how I use SmartPhrases. These are text, ranging from one word, to multiple pages of material, generated by typing the name of the SmartPhrase, preceded by a period.

My approach is to be modular in creating SmartPhrases, as I’ll demonstrate below. I also don’t like to pull in information into my note, such as past history, labs, etc. as the information is already in Epic and it just clutters up the note (I do bring in much of the information for physicals because I think that’s the one time it’s useful to have everything in one note. If acting as a specialist and doing a consultation I might do the same.) Unless I’m doing a physical, which has its own scripts, my baseline script is .soap which looks like this:

Subjective:
@AGE@ @SEX@ with complaints/comments per nursing/medical assistant note, with all such history reviewed for accuracy and confirmed by myself.

The patient’s relevant past medical, surgical and social history was reviewed in Epic.

Objective:
***

Assessment:
***

Plan:
***

@MEF@

Bolding the SOAP elements visually makes it easier to find things. To use a SmartPhrase within a SmartPhrase you just precede and end it with “@”. The final SmartPhrase MEF is just one I created to add the FACP title, which the built in .ME doesn’t.

I usually enter this in my office, reviewing the chart before I go in to see the patient. I then look at my last note (often using a Dragon script to get it quickly) and copy and paste my assessment. Now my note my look something like:

Subjective:
72 year old male with complaints/comments per nursing/medical assistant note, with all such history reviewed for accuracy and confirmed by myself.

The patient’s relevant past medical, surgical and social history was reviewed in Epic.

Objective:
***

Assessment:
1)Hypertension – Suboptimal control.
2)Hyperlipidemia – At NCEP ATP III guidelines.
3)Type 2 Diabetes Mellitus – Uncertain control.

Plan:
***

Daniel C Ginsberg, MD, FACP

Before pasting and still looking at the last note, I also check the plan and often add what I did then to my current note. At the end of first sentence I type the SmartPhrase .ALV (At @HIS@ last visit I) and then add what I did. I use the following SmartLinks all the time in SmartPhrases: @his@, @caphis@, @him@, @he@, @caphe@.

So after typing or using Dragon, the sentence now looks something like, “At his last visit I started him on lisinopril.”

I then check to see what tests the patient has had, and what specialists the patients has seen, and add those at the bottom of the Objective section. I just add the date and make reference such as:

6/12/14 Lab – See report. (the latter created with the SmartPhrase .LSR).
7/2/14 Colonoscopy – See report. (the latter created with the SmartPhrase .CSR).

I try to be consistent with how I name SmartPhrases to make them easier to remember. I also use the Synonyms tab to add other names, especially for ones I have problems remembering.

When recording the history, if you’re not using Dragon, use SmartPhrases for common things to save time, such as .w = with, .co = complains of, .ha = headache.

For the physical exam in Objective, each system as a Smart Phrase, for example:

.GEN
General – Patient appears well in no apparent distress, alert & oriented.

.HEENT
HEENT – PERRLA, EOM with FROM, normal conjunctiva & lids, throat clear, normal lips, gums and teeth, neck symmetric without cervical or supraclavicular adenopathy or mass, thyroid normal

.LUNGS
Lungs – clear to auscultation, no accessory muscle use

.COR
COR – RRR without S3/S4/M, no carotid bruits (Incidentally for the most part I try not to abbreviate creating SmartPhrases since it doesn’t save any time and I don’t want other readers to have guess what it means, but I keep some that are pretty ingrained in clinicians and are unlikely to be confused).

.ABD
Abd – soft, nontender without mass or hepatosplenomegaly

I have variations for each part. For example:

.ABDLUQ
Abd – soft, tender LUQ without guarding, mass or hepatosplenomegaly

.ABDLLQ
Abd – soft, tender LLQ without guarding, mass or hepatosplenomegaly

.EXT2
Extremities – 2+ pedal edema, normal pulses

.GYNE
Gyn – normal external genitalia, urethral meatus, vaginal mucosa and cervix, PAP smear obtained, no adnexal or bladder mass palpated, uterus not palpable

.GYNEH
Gyn – normal external genitalia, urethral meatus, vaginal mucosa, cervix absent, no adnexal or bladder mass palpated, no palpable uterus

I have SmartPhrases for the most common exams I do that combine multiple SmartPhrases.

.BRIEF0
@GEN@
@NECK@
@LUNGS@
@COR@
@EXT@

.BRIEF2
@GEN@
@NECK@
@LUNGS@
@COR@
@EXT2@

I also have multiple SmartPhrases I use to put in the patient instructions section, covering such things as diet, exercise, and instructions on getting lab work. I have one lab instruction that says to fast, with an explanation of what that entails, and one that says it doesn’t matter whether one fasts. Both include some of the labs they can go to and the hours they are open. In between each section I place a line with a SmartPhrase.

.LINE
*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-*-

For a comprehensive book on SmartPhrases, check out Advanced Charting Techniques for EpicCare Physicians: Super Efficiency with SuperPhrases by Peter G Churgin, MD, CCFP. I don’t really use his system as I had developed my own before I read his book, but they are kind of similar.

About Daniel Ginsberg, MD, FACP

I'm an internal medicine physician and have avidly applied computers to medicine since 1986, when I wrote my first medically oriented computer programs. So yes, that means I'm at least 35-years-old!
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15 Responses to Epic SmartPhrases

  1. Heather Davidson says:

    Dr Ginsberg,
    I am wanting to customize a Osteoporosis/Osteopenia/Hyperprathyroidism Nurse Encounter. This Encounter would then be the “spring board” for the provider to use for their Office Visit. The idea is to have the RN’s screen the patient prior to seeing the provider to make the provider visit mroe efficient and streamlined. I hope this makes sense…I currently use smart phrases when I run our Lipidologist’s clinic. The info he needs is much more brief. The Osteo info is quite lengthy…..and I am not sure how to make it work. Heather, RN

    • It depends what you want to do. Certainly you could use a SmartPhrase to write a note. I’m not sure if they are correct, but coders where I’ve worked have said that for billing purposes it’s not enough for a physician to just refer to a nursing note. With that in mind consider which of the elements should go into the Nursing note and what should go into the Physician/Provider note. You can use SmartLinks to pull in data, such as recent labs such as BMP, CMP,PO4, ionized calcium, and PTH, as well a DEXA results. Does that make sense?

  2. eric s. says:

    Great tips. I’ve been using epic for 18 months and didn’t know the @xxx@ within the smartphrase approach. I’m glad you’ve found a good workflow! Thanks for the help.

  3. Vilma Reyes says:

    Dear Dr. Ginsberg: I work for a very busy colon and rectal surgery practice in NJ, and I have created many smartphrases for the MD’s to use; however, I have come across some SmartPhrases that have actually employed check boxes. Any experience with using these? I can’t seem to figure them out, and getting in touch with the analysts–well let’s just say it’s easier said than done.

  4. You can create check boxes in Microsoft Word, then copy them, then paste them into your SmartPhrase. I’m having trouble adding an image to this reply so I’ll send it to you directly.

  5. Billy says:

    Thanks for the tips! I’m an ED scribe who has been looking for ways to maximize efficiency, and your idea for creating dotphrases for commonly used abbreviations is great. Will set up tonight. Thanks again.

  6. Gabe says:

    Great post Dan! I have a similar philosophy about my notes. I love the modular construction approach. It keeps your notes full of content that is actually meaningful by only bringing in what you really think needs to be there on-the-fly.

    I don’t know if you’ll find it helpful, but I have moved to doing APSO notes. They do end up being easier to read when I go back to review the chart in the future, and I get lots of feedback from others that they like APSO notes for reading better as well. What I found with APSO was that it was hard for me to write the A/P first. My work around is that my template is structured as APSO, but I start charting in the Subjective like I always have. I finish with the A/P last in the note creation process, it just happens to be at the top of the note.

    Another hack that I use is the “bulleted number list” in my note template. Instead of:
    Assessment:
    ***

    Mine looks like this:
    Assessment:
    1. ***

    After you type what you want for the first bullet, press enter, and Epic will make a 2. for you, like so:

    Assessment:
    1. Hypertension – Suboptimal control.
    2.

    I love to streamline processes whenever I can so there isn’t any extra manual labor being done. Thanks for sharing such great tips!
    -Gabe

    • Thanks, Gabe. I’ve considered before changing from SOAP to APSO as well, but figured I was the main audience for my notes, and writing it in the order I trained in worked better for me. I have thought about redesigning my note in NoteWriter format, but have yet to tackle that one.

      I previously played around with bulleted lists as well. I ran into some problems copying and pasting inconsistencies. I probably should re-look at doing since it is a little more efficient, though I already created Dragon NaturallySpeaking scripts and can just say, “Problem one,” “Problem two,” etc.

      • gabrieldane says:

        Thank you Dan! Whichever tools work best for specific people, I’m super glad you’re getting this dialogue out there. You’re really a leader in empowering users to think differently and be more successful with Epic! Awesome work!

  7. Brian Wentzel says:

    Dan,

    Thanks so much. I was curious if you knew the best way to take smartphrases you develop with you to another epic environment. For example my wife is a fellow and she is leaving to become an attending. During her fellowship she developed smartphrases she loves. Is there a good way to bring those with her to her next Job(She will be on Epic)? Thanks

    -Brian

    • She can ask her Information Services department to export her SmartPhrases (I believe it can be in the native format or for a spreadsheet (XLS)), which she could save to a disc, USB drive, or online, then they could be imported at her new job. If she has a custom dictionary she can do the same herself.

    • Matt says:

      You can also just open the smartphrases in the smart tool manager and copy-paste into simple text files that can then be copy-pasted into the same manager at her next employer. This assumes that the next employer uses EPIC. It also assumes that things like embedded SmartLists aren’t unique to the institution’s build, but they probably are. For instance, when I recently moved to Multicare my .ROS did not pull up a smart list for review of systems. I had to find the equivalent in the Multicare system and replace it.

  8. richard manthey md says:

    Hi. I enjoy your column. For a lengthy smart phrase, any idea how to move the cursor somewhere other than the end of the phrase? For instance I may have several wild cards in the phrase and would like the cursor to go to the first wild card rather than at the end of the phrase. thanks

    • Thanks. I don’t think that’s possible with a SmartPhrase, though it can be done with a 3rd party program such as a Dragon NaturallySpeaking script or SwiftWire. Ultimately, though, you have to address all the wildcards, so you could just F2 your way through, though I can understand circumstances where you want to deal with something you just typed and save the others for later.

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