A dot phrase is a preformed block of text that is inserted using keyboard shortcuts, often preceded by a dot. The EHR supports the use of dot phrases! We have dot phrases for general criteria by condition, but these must be tailored to each individual. If you would like any Dot Phrases added to the EHR, please submit a request using the Psychiatric Services Providers' form under Web Links in AMD.
Standard dot phrases
Below is a list of the currently available dot phrases in the EHR followed by examples.
.MM
Medication Management
.HPI
Patient is a ** y.o. fe/male, referred by ____ for psychiatric evaluation of *. Patient presents to clinic with a desire to improve
.ADHD
Age of onset, areas of disturbance (home, school, work etc), symptoms
No presence of Mania, Psychosis, Suicidal or Violent thoughts, AH/VH
Denies verbal, physical or sexual trauma
.PHPI
Patient is a ** y.o. fe/male, here for f/u of *. Patient presents with
No presence of Mania, Psychosis, Suicidal or Violent thoughts, AH/VH
.SR
Denies any past suicide attempts. Denies any current thoughts, plans or intent
.MSE
Well groomed - y/o Fe/male with appropriate attire
.Plan
** y/o Fe/male who meets the following DSM5 Criteria:
Patient denies manic episodes, delusions, or hallucinations. Differential dx include
Patient illness affects how they interact in social/occupational/academic environments and community. Maintaining stable health, managing ____, and improving quality of life are currently goals. Given willingness to seek care and supportive treatment, progresses for achieving these goals are promising.
Impression/Plan/Rationale
1. Patient is initiating/continuing/pending medication
2. Safety- Client does not meet criteria for 5150 (DTO, DTS, GD)
3. Collateral- as needed
4. Medical- encouraged regular health checks.
5. Nonpharmacologic- continued medication adherence.
6. Psycho education- Education regarding tx, illness and prognosis was provided to the client along with some medication teaching.
7. Accommodations given: none (For disability include start and return to work date)
.PPlan
** y/o Fe/male here for f/up of ***.
(Patient is in partial remission, remission or not improving with treatment)
Impression/Plan/Rationale
1. Patient is initiating/continuing/pending medication
2. Safety- Client does not meet criteria for 5150 (DTO, DTS, GD)
3. Collateral- as needed
4. Medical- encouraged regular health checks.
5. Nonpharmacologic- continued medication adherence.
6. Psycho education- Education regarding tx, illness and prognosis was provided to the client along with some medication teaching.
7. Accommodations given: none (For disability include start and return to work date)
DSM5 Criteria met:
.ADHD-Hyperactive
Fidgeting, difficult engaging in tasks quietly, restless, often talks excessively, Interrupts others, difficulty waiting and with marked impairment to occupational/social/academic life
.ADHD-Inattentive
Lacks attention to detail, difficulty sustaining attention, difficulty listening when spoken to, does not follow through with tasks/instructions, difficulty staying organized, avoidance of tasks requiring sustained attention/mental effort, often loses items, easily distracted, forgetful in daily activities, and with marked impairment to occupational/social/academic life
.ADHD-Other
Provide rationale for not meeting criteria
.AlcoholUseDisorder
Alcohol consumed in larger amounts than intended, unsuccessful efforts to cut down, great deal of time spent in activities related to attaining using or recovering for the effects of alcohol, cravings, continues use despite negative effects, tolerance, use despite knowledge of personal harm, and withdrawal occurring within a 12-month period
.AnorexiaNervosa1
(Restrictive type) - in partial remission: restriction of intake leading to low body weight, persistent behavior which interferes with weight gain and undue influence of body weight
.AnorexiaNervosa2
(Binge eating and Purging) - in partial remission: restriction of intake leading to low body weight, persistent behavior which interferes with weight gain and undue influence of body weight, recurrent episodes of binge eating and purging over the last 3 months
.BipolarDisorder1
Reported history of several Manic Episode (Grandiosity, talkative, flight of ideas, increased goal directed activity, excessive involvement in activities) lasting at least 1 week AND Depressive episode: low mood, anhedonia, feelings of guilt, low energy, recurrent thoughts of death and hypersomnia which have been present for greater than 2 weeks
.OtherBipolar
Other specified bipolar and related disorder: s/he experiences insufficient symptoms of hypomania. Currently reporting symptoms of increased activity and elevated mood for a duration of time less than the diagnostic criteria needed for Bipolar II
.BingeEatingDisorder
Eating within a period of time an amount of food larger than most under similar circumstances, lack of control during episode, eating when not feeling hungry, embarrassment around eating/eating alone, feeling guilt around eating, marked distress, and is occurring at least once a week for 3 months
.BPD
(5 or more) Pattern of instability of interpersonal relationships, self-image and affects marked impulsivity beginning in early adulthood and present in a variety of contexts: efforts to avoid real or imagined abandonment, unstable and intense interpersonal relationships characterized by alternating between idealization and devaluation, identity disturbance (unstable self-image), impulsivity in at least 2 areas that are self-damaging (spending, sex, substance, binge eating), suicidal behavior, affective instability due to a marked reactivity of mood (intense dysphoria, irritability, or anxiety), difficulty controlling anger, transient, stress-related paranoid ideation or severe dissociative symptoms
.BulimiaNervosa
(partial or full remission) - binge eating, lack of control during over eating episodes, recurrent episodes to prevent weight gain (purging), self-evaluation of weight and body shape, happening at least once a week for 3 months
.DIPD
Drug Induced Psychotic Disorder - Presence of one or both: Delusions, Hallucinations, Symptoms developed soon after substance intoxication or withdrawal or after exposure to a medication, the involved substance is capable of producing the symptoms. Symptoms preceded the onset of the substance and were persistent for a substantial period of time after cessation of acute withdrawal or severe intoxication. Disturbance caused clinically significant distress
.GAD
Given symptoms of excessive worry, restlessness, fatigue, muscle tension, sleep disturbances, and decreased concentration occurring more days than not for over 6 months
.GenderDysphoria
Marked incongruence between one’s experienced/expressed gender and assigned gender. Manifested by at least six of the following (desire to be other gender from ones assigned gender, strong preference for dressing in ways outside of typical feminine/masculine clothing, Strong preference for cross-gender roles in make believe play or fantasy play, strong preference for playmates of other gender, strong dislike for ones sexual anatomy, a strong desire for the primary and/or secondary sex characteristics that match ones experienced. Present for at least 6 months duration
.MDD
Low mood, anhedonia, feelings of guilt/worthlessness, low energy/fatigue, Insomnia/hypersomnia, decreased concentration, and decreased/increased appetite which have been present for greater than 2 weeks
.mental
General: Alert, well groomed, good hygiene, casually dressed
Attitude/Behavior: cooperative, calm, fully engaged in conversation with appropriate eye contact.
Motor Activity: No akathisia, tremor, gait instability or other abnormal movements
Speech: appropriate with regular rate, rhythm, porosity/tone
Mood: (use patients own words)
Affect: normal in range; appropriate to the situation; congruent with mood
Thought process: Linear, coherent, goal directed/logical with abstract thinking
Thought content: No visual or auditory hallucinations or delusions. Denies active SI/HI. No SHB.
Insight: good insight, intact
Judgment: good judgment, intact
Cognition/Memory: Alert and oriented x 4 with appropriate memory and attention
AIMS score checked: Yes ☐ No ☐ N/A ☐
If yes, score: _______
.OCD
Presence of intrusive thoughts causing an increase in anxiety, occurring multiple times a day and causing distress within social relationships
.OpiateUseDisorder
Persistent use despite increased psychological problems caused by use, persistent use despite disruption in social interactions, persistent desire to continue use
.PanicDisorder
Abrupt surge of intense fear along with derealization, chest pain, trembling, feeling faint, fear of losing control, persistent worry about subsequent panic attacks, and avoidance behaviors
.Dysthymia
Persistent Depressive Disorder - low energy, low self-esteem, poor concentration, and hypersomnia, which have been present more days than not for over 2 years
.PMDD
Post Menstrual Dysphoric Disorder - 5 Symptoms present before onset of Menses, improve within a few days after onset and are minimal or absent in weeks post menses. Given symptoms of mood lability, (marked depressed mood, hopelessness or self-deprecating thoughts), Anhedonia, decreased concentration, fatigue, changes in appetite, sense of being overwhelmed, hypersomnia/insomnia, physical symptoms (bloating, weight gain, muscle pain, breast tenderness)
.PTSD
Experience of a physical/verbal/sexual trauma, persistent re-experience, daydreams/flashbacks/nightmares, hyper arousal, avoidance behavior, and hypervigilance
.Schizophrenia
Presence of (Two or more of the following: Delusions, Hallucinations, Disorganized speech, grossly disorganized or catatonic behavior, Negative symptoms (diminished emotional expression)), Diminished self care/work/interpersonal Present for at least 6 months
.Trichotillomania
Recurrent pulling of hair resulting in hair loss, repeated attempts to decrease or stop, hair pulling causes clinically significant distress, not attributed to another medical condition, and not attributed to another disorder
.SHAUD
Sedative, hypnotic, or anxiolytic use disorder (Severe): consumed in larger amounts than intended or for a longer period, unsuccessful efforts to cut down, great deal of time spent in activities related to attaining using or recovering for the effects of substance, failure to obligations at work/school/social, continues use despite negative effects, tolerance, use despite knowledge of personal harm, and withdrawal occurring within a 12-month period
.SSD
Somatic Symptom Disorder - Persistent somatic symptoms that are distressing and disruptive of daily life, disproportionate thoughts about seriousness of symptoms, persistent levels of anxiety about health symptoms, excessive time and energy devoted to health concerns, present for more than 6 months
Updated