Autotext Phrases

These time-saving shortcuts can be used to document anywhere in the EMR. Instructions on how to create a new autotext phrase are here on Cerner's web site.  Copy and paste into the autotext creator, customizing to fit your needs.

INDICATION: _  PROCEDURE OPERATOR: _  ATTENDING PHYSICIAN: _ In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…
Type:           _ Midline        _  Pfannensteil   Staples:     _ Present  …
INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In attendance (Y/N) _   CONSENT:  Consent was obtained from _ prior…
Patient was advised that a baseline colonoscopy is recommended to screen for colorectal cancer. This is a very common disease…
PRE-OP DIAGNOSIS: _  POST-OP DIAGNOSIS: Same  PROCEDURE: endometrial biopsy Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE:  A…
INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _.  In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…
PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same  PROCEDURE: skin lesion excision Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE: …
INDICATION: _  PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…
INDICATION:_ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N)_ Ultrasound Used: Y/N   CONSENT:  Consent was obtained from _…
Constitutional:  No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise ENT/Mouth:  No Hearing Changes, No…
The risks, options, benefits and alternatives of the procedure were discussed including but not limited to bleeding, infection, and potential…
Hep C Initial Visit Dot Phrase First, order a Viral load if antibody positive. If Viral load present then proceed…
HEP C Treatment Visit Dot Phrase. Please read in detail and delete what is not relevant. Do not just copy…
PRE-OP DIAGNOSIS: _  POST-OP DIAGNOSIS: Same  PROCEDURE: incision and drainage of abscess Performing Physician: _  Supervising Physician (if applicable): _…
INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…
PRE-OP DIAGNOSIS: desired long-term, reversible contraception  POST-OP DIAGNOSIS: Same  PROCEDURE: IUD placement Performing Physician: _  Supervising Physician (if applicable): _…
PRE-OP DIAGNOSIS: _  POST-OP DIAGNOSIS: Same  PROCEDURE: IUD removal Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE:  The…
PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same  PROCEDURE: joint injection Performing Physician: _  Supervising Physician (if applicable): _   Lot #…
PRE-OP DIAGNOSIS: lipoma POST-OP DIAGNOSIS: Same  PROCEDURE: lipoma removal Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE:  Anesthesia:…
Preoperative diagnosis: Desires Neonatal Circumcision  Postoperative diagnosis: same  Procedure: Neonatal Circumcision  Operator(s): _ Preprocedure counseling: The risks, benefits, and alternatives…
CC: Newborn HPI Newborn baby _ born to a _ yo G_P_ at _ and _/_ weeks EGA who presented…
The failure rate of 0.05% (1 in 2000), risks, options, benefits and alternatives of the procedure were discussed including but…
PRE-OP DIAGNOSIS: desired long-term, reversible contraception  POST-OP DIAGNOSIS: Same  PROCEDURE: Nexplanon ® placement Performing Physician: _  Supervising Physician (if applicable):…
S: #Opiates: Pt currently using _. Has been using this for _. How the patient got into this is by…
Paracentesis Procedure Note    INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N) _ Ultrasound used to mark…
INDICATION: _  PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…
To whom it may concern,   This patient is able to participate in athletics for as long as they feel…
PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same  PROCEDURE: skin biopsy Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE:  _…
INDICATION:_ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N) _ Ultrasound Used: Y/N   CONSENT:  Consent was obtained from…
INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _  In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…
PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same  PROCEDURE: toenail avulsion Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE:  The…
Tier level: _  Time of Activation: _  Time of Patient Arrival: _  Time of Surgeon Arrival: _  Admitting Trauma Surgeon:…
NEWBORN WT/COLOR CHECK   SUBJECTIVE: _-day old infant born to a _ year old G_ at _ weeks by _.…
  • All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly fradulent.