9. Documentation smart phrases
Disease-specific phrases that supplement the parent module’s phrases. Each is a scaffold to complete with the visit’s actual values and orders — never a substitute for individualized documentation.
.DX_COPD_CARDINAL Cardinal symptoms over the interval: dyspnea [increased/unchanged/improved], sputum volume [increased/unchanged/improved], sputum purulence [increased/unchanged/improved]; number increased [0/1/2/3]; assessment [stable / exacerbation]. |
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.DX_COPD_O2 SpO₂ [value]% on the ordered [flow] L/min; ordered range [range]; oxygen requirement [unchanged/increased]; notify threshold SpO₂ <[floor]%; [action]. |
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.DX_COPD_WOB Work of breathing: accessory-muscle use [none/present], speaks in [full/short] sentences, pursed-lip breathing [used/not]; RR [value]. |
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.DX_COPD_RESCUE Rescue [inhaler/nebulizer] use [frequency] over the interval vs ordered [limit]; escalating [yes/no]; [action]. |
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.DX_COPD_INHALER Observed [device] technique: [correct/corrected]; spacer [used/n-a]; each maintenance device reviewed; oxygen delivery system [tubing/flow/humidification/cannula skin] checked. |
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.DX_COPD_ACTIONPLAN Action-plan step [green/yellow/red]; adherence [described]; yellow/red actions [verbalized correctly/re-taught]; GOLD group [group], exacerbations in past year [number]. |
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.DX_COPD_NOTIFY Provider notified at [time] of [finding]; orders received: [orders]; follow-through [completed/scheduled]; reassess [cardinal symptoms / SpO₂ on ordered flow] next visit. |
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Cross-references. Respiratory (parent — full lung exam and breath sounds) · Cardiovascular (cor pulmonale, edema) · Nose/Sinuses (cannula skin) · Diabetes overlay (steroid-induced hyperglycemia) · Anxiety/Coping (dyspnea-related anxiety).