> ## Documentation Index
> Fetch the complete documentation index at: https://docs.scribe.commure.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Custom Formatting Examples

Example custom formatting rules you can use as inspiration when setting up Commure Scribe.

<Tip>
  Hi! Here is a guide on how to best structure your custom rules when using Commure Scribe.
</Tip>

## Formatting Examples

* When documenting pain levels, write it as a number out of 10 in numerals.
* Create a numbered problem list based on subjective and objective.
* After the Assessment section, add a section called Assessment/Objective to include a one paragraph summary combining the Assessment and Objective sections and justifying the need for continued PT (unless the patient is to be discharged).
* Create a list of patient goals and/or progress towards goals based on subjective and objective.
* Create a comma-separated list of all neuromuscular re-education performed under the heading Neuromuscular Re-education.
* Create a comma-separated list of all therapeutic activities performed under the heading Therapeutic Activities.
* Create a comma-separated list of muscles released through dry needling and/or dry needling protocols used; include, if used, the amount of time electrical stimulation with needling was done (under the heading Dry Needling).
* Create the Assessment as a narrative of what the PT did that day and how the patient responded.
* Never write the subjective, objective, assessment, or plan in a numbered list.
* Always document general exam.
* If I am talking to the scribe before the start of a visit this is all considered important information and should be included in the documentation.

## Style

* Refer to the patient by their name instead of patient.
* Never write a note in the first person.
* Always abbreviate physical therapy as PT.
* The provider addressing the patient is always the physical therapist.
* Refer to the PT as Therapist.

## Dot Phrases

* When I say "ears look good" replace with "Right canal is clear, Tympanic membrane is grey with normal light reflex, Left canal is clear, Tympanic membrane is grey with normal light reflex. no effusions."
* When I say "mouth looks good" replace with "mucous membranes are moist, teeth in good repair, posterior pharynx is without erythema, without exudate."
* When I say "heart is good" replace with "heart is regular, no murmurs, rate is normal."
* When I say "lungs sound good" replace with "lungs with good airflow, no wheeze" — start recognizing key phrases to note that the area was examined and not document "not examined."
* "I'm going to listen to your neck" or "swallow for me" = neck exam.
* "just breath normal for me" = heart exam.
* "big deep breath" = lung exam.
* "lay back here I'm going to feel your belly" = abdominal exam, etc.
* "any fluid in your legs" = extremities.
* Instead of saying "no information provided" just leave the entire section blank, leave it out. For example in the physical exam instead of saying "abdomen - no information or not examined" just delete the abdomen portion of the exam.
* If I ask the patient particular medical questions include the patient's answers in the history. For example "are you checking your sugars at home", "are you checking your blood pressure at home", "how long has the symptom been present", "are there other associated symptoms". If I ask the patient a series of questions related to a certain concern or complaint all their answers should be documented.