"Documenting an exam on paper is faster because we develop our own shorthand."

Starting with this "paper" shorthand, we forged an electronic Shorthand, specifically designed for rapid data entry.
Using Shorthand, all your findings are entered in one text box, and OpenEMR automatically knows how to store them.

The structure is simple: Field:text;Field:text;Field:text

Click on any Shorthand icon in the Eye Form and two things occur:

The Shorthand textbox opens
Shorthand Field names are visible

In the Shorthand textbox, type the Field name, then a colon, followed by your findings.

Look around the form - openEMR: Eye Exam is automatically filled.
Done. No extra clicks.

This tutorial shows you how to document each area using Shorthand.
We'll show you how to complete the HPI, PMH, POH, Medication list, Surgical History and Allergies.
As an example, using a handful of lines of typing in the Shorthand textbox,
you will document all your normal findings and more than 40 different clinical issues.
That's a lot to document and one mighty complicated patient!
Combined it may be many more issues than we would see on a routine day, with routine patients, but it could happen...
Documenting this many findings would take a little bit of time on paper, and a lifetime in a typical EHR.
The average typist can now do it in less than a minute. A normal encounter can be accurately documented in seconds.

HPI:

PMH:

External:

Anterior Segment:

Retina:

Strabismus:

Below all these lines are strung together. Copy and paste this into a test patient's chart.
Voila! HPI, PMH, POH, Medications Allergies and 40 clinical findings + normals, are documented.

CC:"My eyes are tearing and there is a yellow discharge";hpi:The symptoms began last week and the discharged turned yellow yesterday.  No photophobia.  The redness spread from the right to the left eye two days ago.;
                                POH:POAG. Myopia. Dry Eye; POS: Phaco/IOL OD 4/4/1994.Phaco/IOL OS 4/24/1995. Yag/PCO OD 6/5/1999;Meds:Timolol 0.5% GFS QHS OU. Latanoprost 0.01% QHS OU.
                                Trazadone 50mg PO QHS.Famvir 500mg PO TID;Surg:Appendectomy 1998. Choly 2010.Lap Band 2014.;All:sulfa - hives.PCN - SOB;
                                D;bll:+2 meibomitis;rll:frank ect, 7x6mm lid margin bcc lat.a;bul:2mm ptosis;rul:+3 dermato.a
                                bc:+2 inj;bk:med pter;rk:mod endo gut.a;bac:+1 fc, +1 pig cells;
                                bd:+2 bowtie pallor;rcup:0.6Vx0.4H w/ inf notch;lcup:0.5;rmac:+2 BDR, +CSME;lmac:flat, tr BDR;v:+PPDR, ++venous beading;rp:ht 1 o,no vh;
                                scDist;5:8ix 1rht;4:10ix;6:6ix;2:15xt;8:5ix;ccDist;4:5ix;5:ortho;6:ortho

Get back to working at the speed of your brain.

Now imagine documenting this without typing, without a scribe? It is not that far away...

Usage: field:text(.a)(;)

where:
Field is the shorthand term for the clinical field.
text is the complete or shorthand data to enter into this field:
field and text are separated by a ":" colon.
The trailing ".a" is optional and will append the text to the data already in the field, instead of replacing it.
The semi-colon ";" is used to divide entries, allowing multiple field entries simultaneously.
The semi-colon separates entries.
After pressing Enter/Return or Tab, the data are submitted and the form is populated.

Shorthand

Input:

D;bll:+2 meibomitis;rll:frank ect, 7x6mm lid margin bcc lat.a;bul:2mm ptosis;rul.+3 dermato.a

Output:

Eye Exam

Reports

Clinical Field	Shorthand* Field	Example Shorthand**	EMR: Field text
Default values	D or d	d; D;	All fields with defined default values are erased and filled with default values. Fields without defined default values are not affected.
Default External values	DEXT or dext	dext; DEXT;	All External Exam fields with defined default values are erased and filled with default values. External Fields without defined default values and all other fields on the form are not affected.
Right Brow	rb or RB	rb:1cm lat ptosis rb:med 2cm SCC	1cm lateral ptosis medial 2cm SCC
Left Brow	lb or LB	lb:loss of lat brow follicles lb:no rhytids from VIIth nerve palsy	loss of lateral brow follicles no rhytids from VIIth nerve palsy
Both Brows/Forehead	fh or FH bb or BB	fh:+3 fh rhytids BB:+3 glab rhytids	+3 forehead rhytids +3 glabellar rhytids
Right Upper Lid	rul or RUL	RUL:1cm lat ptosis rul:med 2cm SCC	1cm lateral ptosis medial 2cm SCC
Left Upper Lid	lul or LUL	LUL:1cm lat ptosis lul:med 2cm SCC	1cm lateral ptosis medial 2cm SCC
Right Lower Lid	rll or RLL	rll:1cm lat ptosis rll:med 2cm SCC	1cm lateral ptosis medial 2cm SCC
Left Lower Lid	lll or LLL	lll:0.5cm lat ptosis LLL:med 2cm SCC	1cm lateral ptosis medial 2cm SCC
Both Lower Lids	bll or BLL	lll:0.5cm lat ptosis LLL:med 2cm SCC	1cm lateral ptosis medial 2cm SCC
All 4 Lids	4xl or 4XL	4xl:+2 laxity 4xL:+2 dermato	+2 laxity +2 dermatochalasis
Right Medial Canthus	rmc or RMC	rmc:1cm bcc RMC:healed dcr scar	1cm BCC healed DCR scar
Left Medial Canthus	lmc or LMC	lmc:acute dacryo, tender w/ purulent drainage lmc:1.2cm x 8mm mass	acute dacryo, tender with purulent drainage 1.2cm x 8mm mass
Both Medial Canthi	bmc or BMC	bmc:chronic dacryo, non-tender BMC:scaling, ulcerated lesion	chronic dacryo, non-tender scaling, ulcerated lesion
Right Adnexa	rad or RAD	rad:1.8x2.0cm bcc lat RAD:healed DCR scar	1cm BCC healed DCR scar
Left Adnexa	lad or LAD	lad:1cm lacr cyst protruding under lid LAD:1.2cm x 8mm mass	1cm lacrimal cyst protruding under lid 1.2cm x 8mm mass
Both Adnexae	bad or BAD	bad:lacr gland prolapse BAD:lat orb wall missing	lacrimal gland prolapse lateral orbital wall missing

*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "4xL:+2 meibomitis.a" will append "+2 meibomitis" to each of the eyelid fields, RUL/RLL/LUL/LLL.

External Shorthand Abbreviations:

The following terms will be expanded from their shorthand to full expression in the EMR fields:

Enter this:	Get this:
inf	inferior
sup	superior
nas	nasal
temp	temporal
med	medial
lat	lateral
dermato	dematochalasis
w/	with
lac	laceration
lacr	lacrimal
dcr	DCR
bcc	BCC
scc	SCC
sebca	sebaceous cell
tr	trace

Shorthand

Input:

D;bc:+2 inj;bk:med pter;rk:mod endo gut.a;bac:+1 fc, +1 pig cells

Output:

Eye Exam

Reports

Clinical Field	Shorthand* Field	Example Shorthand**	EMR: Field text
Default values	D or d	d; D;	All fields with defined default values are erased and filled with default values. Fields without defined default values are not affected.
Default Anterior Segment values	DANTSEG or das	dantseg; DAS;	All Anterior Segment fields with defined default values are erased and filled with default values. Anterior Segment Fields without defined default values and all other fields on the form are not affected.
Conjunctiva	Right = rc Left = lc Both = bc or c	rc:+1 inj c:med pter	"+1 injection" (right conj only) "medial pterygium" (both right and left fields are filled)
Cornea	Right = rc Left = lc Both = bk or k	rk:+3 spk k:+2 end gut;rk:+1 str edema.a	"+3 SPK" (right cornea only) "+2 endothelial guttatae" (both cornea fields) AND "+1 stromal edema" (appended to Right cornea field)
Anterior Chamber	Right = rac Left = lac Both = bac or ac	rac:+1 fc ac:+2 flare	"+1 flare/cell" (right A/C field only) "+2 flare" (both A/C fields)
Lens	Right = rl Left = ll Both = bl or l	RL:+2 NS ll:+2 NS;l:+3 ant cort spokes.a	"+2 NS" (right lens only) "+2 NS" (left lens fields) AND "+3 anterior cortical spokes" (appended to both lenses)
Iris	Right = ri Left = li Both = bi or i	bi.12 0 iridotomy ri:+2 TI defects.a;li.round	"12 o'clock iriditomy" (both iris fields) ", +2 TI defects" (right iris field) AND "round" (left iris field only)
Gonio	Right = rg Left = lg Both = bg or g	rg:ss 360 lg:3-5 o angle rec	SS 360 3-5 o'clock angle recession
Pachymetry	Right = rp Left = lp Both = bp or p	lp:625 um p:550 um	"625 um" (left pachymetry field) "500 um" (both pachymetry fields)
Schirmer I	Right = rsch1 Left = lsch1 Both = bsch1 or sch1	rsch1:5mm sch1:< 10mm/5 minutes	"5mm" (right field only) "< 10mm/5 minutes" (both fields)
Schirmer II	Right = rsch2 Left = lsch2 Both = bsch2 or sch2	rsch2:9 mm sch2:< 10mm/5 minutes	"9 mm" (right field only) "< 10mm/5 minutes" (both fields)
Tear Break-up Time	Right = RTBUT Left = LTBUT Both = BTBUT or tbut	tbut:< 10 seconds Rtbut:5 secs;ltbut:9 seconds;	"10 seconds" (both fields) "5 seconds" (right) AND "9 seconds" (left)

*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "bk:+2 str scarring.a" will append"+2 stromal scarring" to both the right (rk) and left cornea fields (lk).

External Shorthand Abbreviations:

The following terms will be expanded from their shorthand to full expression in the EMR fields:

Enter this:	Get this:
inf	inferior
sup	superior
nas	nasal
temp	temporal
med	medial
lat	lateral
dermato	dematochalasis
w/	with
lac	laceration
lacr	lacrimal
dcr	DCR
bcc	BCC
scc	SCC
sebca	sebaceous cell
tr	trace

Shorthand

Input:

D;bd:+2 bowtie pallor;rcup:0.6Vx0.4H w/ inf notch;lcup:0.5;rmac:+2 BDR, +CSME;lmac:flat, tr BDR;v:+PPDR, ++venous beading;rp:ht 1 o,no vh;

Output:

Eye Exam

Reports

Clinical Field	Shorthand* Field	Example Shorthand**	EMR: Field text
Default values	D or d	d; D;	All fields with defined default values are erased and filled with default values. Fields without defined default values are not affected.
Default Retina values	DRET or dret	dext; DEXT;	All Retina/Posterior Segment Exam fields with defined default values are erased and filled with default values. Retinal Fields without defined default values and all other fields on the form are not affected.
Disc	Right = rd Left = ld Both = bd	rd:temp pallor, PPA bd:NVD at 5 o	"temporal pallor, PPA" (right disc only) "NVD at 5 o'clock" (both right and left disc fields)
Cup	Right = rcup Left = lcup Both = bcup or cup	rcup:0.5 w/ inf notch cup:temp scalloping, 0.5.a;	"0.5 with inferior notch (right cup only) "temporal scalloping, 0.5" (appended to both cup fields)
Macula	Right = rmac Left = lmac Both = bmac or mac	rmac:central scar 500um mac:soft drusen, - heme.a	"central scar 500um" (right macular field only) "soft drusen, - heme" (appended to both macular fields)
Vessels	Right = rv Left = lv Both = bv or v	RV:1:2, +2 BDR lv:+CSME w/ hard exudate sup to fov (300um); v:narrow arterioles, 1:2.a;	"1:2, +2 BDR" (right vessels only) "+CSME with hard exudate superior to fovea (300um)" (left vessel field only) "narrow arterioles, 1:2" (appended to both vessel fields)
Periphery	Right = rp Left = lp Both = bp or p	rp:12 0 ht, no heme, amenable to bubble; bp.1 clock hour of lattice 2 o.a;	"12 o'clock horseshoe tear, no heme, amenable to bubble" (right periphery field) "1 clock hour of lattice 2 o'clock" (appended to both periphery fields)
Central Macular Thickness	Right = rcmt Left = lcmt Both = bcmt or cmt	rcmt:254 cmt:flat	254 (right CMT only) flat (both CMT fields)

*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "bcup:0.5 w/ inf notch.a" will append "0.5 with inferior notch" to both the right (rcup) and left cup fields (lcup).

Retina Shorthand Abbreviations:

The following terms will be expanded from their shorthand to full expression in the EMR fields:

Enter this:	Get this:
inf	inferior
sup	superior
nas	nasal
temp	temporal
med	medial
lat	lateral
csme	CSME
w/	with
bdr	BDR
ppdr	PPDR
ht	horsheshoe tear
ab	air bubble
c3f8	C3F8
ma	macroaneurysm
tr	trace
mias	microaneurysm
ped	PED
1 o	1 o'clock
2 o	2 o'clock
3 o	3 o'clock
4 o	4 o'clock
5 o	5 o'clock
6 o	6 o'clock
7 o	7 o'clock
8 o	8 o'clock
9 o	9 o'clock
10 o	10 o'clock
11 o	11 o'clock
12 o	12 o'clock
mac	macula
fov	fovea
vh	vitreous hemorrhage

Shorthand

Input:

scDist;5:8ix 1rht;4:10ix;6:6ix;2:15xt;8:5ix;ccDist;4:5ix;5:ortho;6:ortho;

Output:

Eye Exam

Reports

Clinical Field	Shorthand* Field	Example Shorthand**	EMR: Field text
Default values	D or d	d; D;	All fields with defined default values are erased and filled with default values. Fields without defined default values are not affected.
Without correction at Distance	scDist	scdist;	scDIST is selected for ensuing values.
With correction at Distance	scDist	ccdist;	ccDIST is selected for ensuing values.
Without correction at Near	scNear	scdist;	scDIST is selected for ensuing values.
With correction at Near	scNear	scdist;	scDIST is selected for ensuing values.

*case insensitive
**The default action is to replace the field with the new text.
Adding ".a" at the end of a text section will append the current text instead of replacing it.
For example, entering "4:5ix.a" will append "5 X(T)" to any measurements previously entered into the right gaze field.

Neuro Shorthand Abbreviations:

The following terms will be expanded from their shorthand to full expression in the EMR fields:

Strabismus	Enter this:	Get this:
Exophoria	x	X
Intermittent Esotropia	ie or e(t)	E(T)
Esoptropia	et	ET
Esophoria	e	E
Intermittent Exotropia	ix or x(t)	X(T)
Exoptropia	xt	XT
Hyperphoria	h	H
Intermittent Hypertropia	H(T)	H(T)
Hypertropia	rht lht	RHT LHT
Hypotropia	hyt	HyT

Introduction: Paper vs. EHR

HPI:

PMH:

External:

Anterior Segment:

Retina:

Strabismus:

Shorthand Structure

Usage: field:text(.a)(;)

History of Present Illness: Shorthand Walk Through

Shorthand

Past Medical History: Shorthand Walk Through

Shorthand

External: Shorthand Walk Through

Shorthand

External: Example Output

Eye Exam

Reports

External: Field Codes and Shorthand/Abbreviations

External Shorthand Abbreviations:

Anterior Segment: Shorthand Walk Through

Shorthand

Anterior Segment: Example Output

Eye Exam

Reports

Anterior Segment: Field Codes and Shorthand/Abbreviations

External Shorthand Abbreviations:

Retina: Shorthand Walk Through

Shorthand

Retina: Example Output

Eye Exam

Reports

Retina: Field Codes and Shorthand/Abbreviations

Retina Shorthand Abbreviations:

Neuro: Shorthand Walk Through

Shorthand

Neuro: Example Output

Eye Exam

Reports

Neuro: Field Codes and Shorthand/Abbreviations

Neuro Shorthand Abbreviations: