EHR narrative text variables and merge fields
EHR narratives provide the following system default text variables (custom text that you define) and merge fields (data that is pulled from a patient's record):
Narrative Fields (text variables)
Anesthesia
Follow-up visit
1 week
10 days
2 weeks
24 hours
48 hours
PRN
General Anesthesia
Vital Signs
Blood Pressure
Intra-op
Post-op
Pre-op
Pulse
Intra-op
Post-op
Pre-op
Pulse Oximeter
Intra-op
Post-op
Pre-op
Intravenous sedation
Blood pressure
Intra-op
Post-op
Pre-op
Pulse
Intra-op
Post-op
Pre-op
Pulse Oximeter
Intra-op
Post-op
Pre-op
IV Site
Type
20 guage
23 guage
Left arm
Left hand
Other site
Right arm
Right hand
Local
0.5% Marcaine with epinephrine
2% Xylocaine 1:100,00 epinephrine
3% Carbocaine
4% Septocaine 1:100,00 epinephrine
Medical History
Confirm NPO
Except medications
Confirm Medical Hx.
Confirm Tx. Plan
Medications
Brevital
Fentanyl
Propofol
Versed
Airway management
Circulator
Consent signed
Nitrous Oxide/Oxygen Analgesia
Post-operative instructions
Surgical assistant
Biopsy
Excision of benign lesion
Base of tongue
Floor of mouth
Hard palate
Lip
Salivary gland
Soft palate
Excision of malignant lesion
Base of tongue
Floor of mouth
Hard palate
Lip
Salivary gland
Soft palate
Dental History
Chief Complaint
Duration
History of present illness
Dentoalveolar Surgery
Alveoplasty
With extractions
Without extractions
Cyst
Radicular
Extraction of erupted teeth
Routine
With split
Without split
Impacted teeth
Full bony impaction
Nerve seen - not intact
Nerve seen and intact
Sinus floor intact
Sinus opening noted
Partial bony impaction
Implant surgery
Intraosseous implant
Surgical extraction
With split
Without split
Apicoectomy
Frenectomy
Root extraction
Examination
Existing Patient
Initial
Medications
Antibiotics
Amoxicillin
Ampicillin
Clindimycin
EES
Penicillin
Pain
DarvocetN 100
Lortab
Panlor
Percodan
Tylenol #3
Sedative
Halcion
Valium
Orthognathic Surgery
Genioplasty
LeFort I Osteotomy
Malar augmentation
Sagittal Split Osteotomy
Past Medical History
Medical Problems
Allergies
ASA
Codeine
EES
Latex
Penicillin
Sulfa
Bleeding
Anemia
Hemophilia
Prolonged bleeding
Sickle Cell trait
Blood thinners
ASA
Coumadin
Cancer
Chemotherapy
Head and neck cancer
Radiation treatment
Diabetes
Diet controlled
Insulin Control
Oral medication
Heart Murmur
Functional
Organic
Kidney
Dialysis
Liver
Hepatitis A
Hepatitis B
Hepatitis C
Lung problems
Asthma
Exercise induced
Inhaler controlled
Oral medications
Emphysema
Tuberculosis
AIDS
Antibiotic Premedication
Chest pain
Coronary blockage
Fainting spells
Glaucoma
Heart attack
Heart problems
Heart valve replacement
High Blood Pressure
HIV
Low Blood Pressure
Low blood sugar
Malignant Hyperthermia
Medications
Rheumatic fever
Seizure disorder
Stroke
Venereal disease
Physical Exam
Extremities
Radial pulse
Not present
Present
Clubbing
Cyanosis
Strong peripheral pulse
Head and Neck
TMJ
Crepitus
Fremitus
FROM
No lymphadenopathy
Normocephalic
Restricted ROM
Submandibular lymphadenopathy
Heart
Murmurs
Diastolic murmur
No murmur
Systolic murmur
NSRR
S1/S2 audible
S4 audible
Sinus rhythm
Systolic murmur
Lungs
Equal/bilateral breath sounds
No rales
No wheezes
Wheezing
Neurologic
Facial muscle weakness
Facial sensory loss
Generalized weakness
No gross neurologic deficits
Paralysis
WNL
Psychiatric
Alert
Person
Place
Time
Anxious
Calm
Combative
Cooperative
Deferred
Mentally handicapped
Normal
Uncooperative
Surgical Risk
ASA 1
ASA 2
ASA 3
ASA 4
Postoperative
Dry socket
Additional treatment
Initial treatment
Edema
Mild
Moderate
Severe
Area healing WNL
Food trapping
Monitor bony ridge
Pain
Preprosthetic Surgery
Alveolar right bone graft
Torus/Tori removal
Tuberocity reduction
Vestibuloplasty
Radiography
Cephalometric x-ray
Occlusal x-ray
Panoramic x-ray
Perioapical x-ray
TMJ x-ray
Social History
Alcohol use
Drug use
Tobacco use
TMJ
Diagnosis
Common migraine
Dislocation - closed lock
Dislocation - open lock
Facial pain - atypical
Functional jaw abnormality
Osteoarthritis
Spasm of TMJ
TMJ adhesion
TMJ ankylosis
TMJ ligament pain
EHR Case Fields (merge fields)
Patient
Medical History
Allergies
Allergies
Allergies-Insertable Table
Photo
Case Summary
Case Date Summary
Case Type
Provider
Provider Name
Signature
Digital
Electronic
Dates
Tx Started, Tx Completed, and Finish Date
Tx Started
Tx Completed
Finish Date
Record
Chief Complaint
History of Present Illness (HPI)
Dental
Dental
Dental-Insertable Table
Orthognathic
Orthognathic
Orthognathic-Insertable Table
TMJ
TMJ
TMJ-Insertable Table
Medical Forms
Medical Forms
Medical Forms-Insertable Table
History
Medical History
PMHx
PMHx-Insertable Table
Social History
PSHx
PSHx-Insertable Table
Family History
PFHx
PFHx-Insertable Table
Surgical History
SurgHx
SurgHx-Insertable Table
History Surveys
Hx
Hx-Insertable Table
Pain and Swelling
Pain and Swelling
Pain and Swelling-Insertable Table
Pain and Swelling List-Insertable Table
Medications
Medications
Medications Active Only
Medications-Insertable Table
Medications Active Only-Insertable Table
Vital Signs
Vital Signs-All
Vital Signs-Last 30 days
Vital Signs-Last 7 days
Vital Signs-Today
Vital Signs-Insertable Table
Note: Not every Vital Signs reading is included in lists or tables. The Vital Signs readings are printed using the following criteria:
First and last readings
Readings that include a blood pressure reading
Readings taken every three minutes from first reading
Review of System
Review of System
Review of System-Insertable Table
Implants
Implants
Implants-Insertable Table
Readings-Insertable table
Exams and Tests
Exams and Tests
Exams and Tests-Insertable Table
Exams and Test CrossTab-Insertable Table
All
Tests
Swelling
Other
XRay
Perio
Diagnosis
Teeth
Teeth
Teeth-Insertable Table
Tooth Selector
Canals
Canals
Canals-Insertable Table
Anesthesia and Medications Administered
Anesthesia and Medications Administered
Anesthesia and Medications Administered-Insertable Table
Treatment and Post-Op
Treatment and Post-Op
Treatment and Post-Op-Insertable Table
Images
Images
Images-Caption
Images-Insertable Table
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