Learning the Basics
You should see something like this when you open TextExpander.
In the Shared section you should see a snippet group called ▶ statnote – primary care library.
If you click on the right-pointing triangle ▶ you can see all the templates or dot phrases. TextExpander calls them snippets.
There are over 1,000 templates. The best way to familiarize yourself with all of them is by getting our book on Amazon.
There are two ways in which you can prompt a dot phrase. The first one is by typing the abbreviation. (i.e. for anemia it would be ,.anemia). All the abbreviations have a prefix of a comma and a period (,.). You can modify your prefix in the Snippet Group Settings.
It would be almost impossible to learn all the 1,000+ dot phrase abbreviations. But there is an easier way. You can use a in-line search bar. Simply press the following hotkey:
For Windows: Ctrl + /
For Mac: ⌘ Cmd + /
You can search for the dot phrase with different keywords. For example, for actinic keratosis you could use either ak or actinic keratosis. You could even type the first few letters of of the words (act ker) and the result should still come up. See below for other examples.
Most conditions have two dot phrases: one that pertains to the history of present illness (HPI), or subjective part of the note, and one that pertains to the assessment and plan (A/P) part of the note (i.e ,.htn-hpi, and ,.htn#). The dot phrase for the A/P part usually has # as a suffix. The -hpi suffix is generally used for only short acronyms such as HTN or AK.
Some dot phrases have a -PE suffix for the physical exam section (i.e. acne, acne-PE and acne#).
Some conditions have up to five different templates. (i.e. ,.carpal-tunnel, ,.carpal-tunnel-PE, ,.carpal-tunnel#, ,.carpal-tunnel-inj, and ,.carpal-tunnel*). Note how the -hpi suffix was not used in this case.
dot phrase suffix and prefix legend
|prefix/suffix||dot phrase type|
|-inj||injection - procedure documentation|
|em-||E/M visit codes|
|lab-||lab results messages|
|xray- or us-||imaging results messages|
You might have noticed above the physical exam template used. The main template you can use is “no-touch” (everything documented can be gathered from entering the room, saying hi to the patient and shaking his or her hand.) This template covers nine organ systems or elements required to be documented for billing purposes. Try to start with the “no-touch” template and then add elements of the physical exam pertinent to the visit. (like carpal tunnel exam in the above example.)
You will see multiple templates in other sections with the suffix -PE (i.e. ,.acne-PE, ,.knee-PE). Other templates (like abdomen, ent, cardiopulm) are categorized based on the organ system pertinent to the visit. When listening to the patient’s heart and lungs, use the cardiopulm template.
Some dot phrases are used as only documentation for billing purposes. For example, with transitional care management for hospital follow-ups (,.hospital f/u), providers must document that the patient was contacted within two business days.
The templates have concise and relevant information regarding the different conditions being documented. You should always edit the templates in order to document accurately. For some complex patient presentations, it is better to dictate or write the old-fashioned way. Finally, you should always read your notes before you sign them.
Contact us for any questions or leave a comment below.
See the dot phrases in action: