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-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-Insertable Table

· Orthognathic

· Orthognathic-Insertable Table

· TMJ

· TMJ-Insertable Table

· 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-Insertable Table

· Pain and Swelling List-Insertable Table

· 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-Insertable Table

· 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

Need more help?

You can visit our website, contact OMSVision Customer Support, or suggest a new feature or improvement on User Voice.