Macro's: Decrease Repetition

Macros:

Macros can be extremely helpful. They can speed up your note writing, speed up your discharge instructions, and ultimately free up time while on shift to focus on things that are more important, such as patient care. Before getting into how I use macros, it is very important to state that macros certainly have their issues.

They should not be used unless the presentation and your work up were by the book, and of low overall concern. You do not want to use a macro when discussing a nuanced case or a case where many critical actions occurred. Only use macros when they replace simple everyday comments, tasks, or discussions.

Another flaw with macros is when they state too much. Imagine having a note state “Dorsalis Pedis pulses bilaterally +2,” but the patient in reality has a right sided BKA that was never mentioned. It will become quite obvious that you used a macro and your note will not be true to the patient’s actual current state.

With all that said, it is much better to keep your macros very basic, and allow for free typing of the more important information. These are called “incomplete macros” and generally only auto populate the things that you will know to be true for most patients. Incomplete macros also are helpful when they reiterate something you do on a regular basis that does not change patient to patient, such as preparation for Lac repair or I&D abscess drainage. Your process is the same every time and therefore your note will be the same every time.

Now that this disclaimer is over, I will show you how you might be able to use macros effectively.

Multiple types of physical exams.

1. A Triage screening physical exam that is brief and not overstated.

2. A Basic full physical exam which is slightly more detailed that can be uses with most patients that are in gowns and in a hospital bed.

3. A neurologic physical exam that leaves the neurologic section blank so that you can fill this in with the important details.

4. A respiratory physical exam that leaves the respiratory section blank so that you can fill in the important details of this portion of the exam.

5. An obtunded and altered physical exam that reflects an exam done on someone who you are unable to gauge patient response. This exam leaves out comments, such as “tenderness with palpation, sensation intact, etc.”

6. A pediatric physical exam for children between the ages of three and 12. This exam would reflect a normally developing child who can have conversation and interact during physical exam.

7. An Infant Physical exam which reflects a normal infant exam, including normal reflexes, normal fontanelle, diaper exam etc.

Discharge Macro:

Discharge instructions are a very important part of your care. It is recommended that you give detailed and descriptive instructions regarding how to take care of the illness at home, who to follow with, and what to present back to the emergency department for.

This is made much easier with macros. I put my macro on top of the prefab instructions in discharge 123.

 My discharge macro reads:

“ Thank you so much for letting us take care of you here at Maria Parham Emergency department.

You were seen today for your *blank*.

To take care of this at home please [**]

Please call 911 or present back to the emergency department immediately if you develop [*x,y,z*] or any of the symptoms or signs discussed at bedside.

Please ensure you follow up with your primary care provider in the next 24 to 48 hours by making a phone call. They can help go over results, and help you better manage taking care of yourself at home.

Please follow up with any specialists as we discussed at bedside in the next 24 to 48 hours to ensure you get the proper ongoing care necessary.

Medications to take:

Ibuprofen 600 mg every six hours

Acetaminophen 500 mg every six hours

It is dangerous to take more than the above doses.”

As you can see, I have given very important details, in clear terms, so that the patient can follow instructions easily.

With this as my base discharge template I am then able to add even more detailed instructions. I have done this for rib fractures, instructing the patient to “use incentive spirometry once every 15 minutes, cough into a pillow, and adequate pain control” and I have done this for infant RSV bronchiolitis, discussing “nasal suctioning before feeds and ever 2 hours, adequate fever control, humidified air, and light chest PT.

These above discharge instructions are relatively detailed, and are unlikely to change patient to patient.

If I weren’t able to use macros for these discharge instructions it would either take much longer to get this detailed or I would have to shorten up my instructions. Both of these options are not ideal.

MDM macro

I have created an MDM macro which helps focus my mind on the important information I need to mention and pre-fills the normal medical jargon I use for just about every note.

It reads:

“Vitals: reviewed as detailed above.

EKG:

Lab work / imaging: all lab work and imaging was personally evaluated and interpreted.  

Workup and management:

·        .

·        .

Repeat evaluation: upon my evaluation after the above work up and treatment, the patient has improved symptoms, appears nontoxic, and safe for discharge.

Diagnosis:

Disposition: discharge to follow with primary care and recommended specialists if applicable

I have discussed with the patient or their caregiver, in my normal customary fashion, the work-up and management done here in the emergency department. I’ve discussed the diagnosis, other important incidental findings and the provisional nature of such. I have given the patient or caregiver instructions regarding how to best manage their illness at home, who to follow up with, and what would warrant a return to the emergency department. I have answered all questions asked to the best of my ability.”