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Chief Editor Natgleason
Created Jul 5, 2019
Last edited Jul 30, 2019
All contributors WikiVisor, Psanger, Natgleason
Sharing policy Public
Edit policy Allowed
Organ system Cardiovascular
Medical field General Internal Medicine
Patient population Adult
Setting Outpatient
Type Diagnosis
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Accurate  : 13    
Evidence based  : 16.7    
Efficient  : 21.7    

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Hyperlipidemia and Coronary Disease Risk Assessment:

This patient does not have a personal history of smoking, hypertension, diabetes, or family history of early CAD. We discussed diet and exercise and the determined that the following changes have the greatest potential. ***

Assessment and Plan

- statin

Best practices
Suggestions (not requirements):

1. Your dotphrase can contain any/all of Subjective (S), Objective (O), Assessment/Plan (AP), Patient Info (PI), or Admin/Other (AO). It can address a known diagnosis or an undifferentiated complaint. Encourage focusing on Assessment/Plan since this is the most challenging and not many existing dotphrases cover this.

2. Please include evidence where appropriate, e.g.:

  • for Subjective and Objective elements, cite likelihood ratios or sensitivity/specificity
  • for assessment/plan, cite NNT/NNH for treatments and/or clinical decision rules
  • cite references
  • include links to shared decision aids

3. Write text in such a way as it can be directly used without editing, (eg, "The patient denied x, y, z" rather than "x, y, z?")

4. If S/O/AP have significant branch points, (eg, micro/normo/macrocytic anemia), indicate that and write separate text that is appropriate to each with the understanding that the other branches' text can be deleted.

5. For plans, try to include first, second and/or third line workup.

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