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Autotext Dot Phrases for Cerner EHR

All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only for educational purposes.  Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient.  Do not merely copy and paste a prewritten note element into a patient's chart - "cloning" is unethical, unsafe, and potentially fradulent.

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  • venturafamilymed
    • Sep 8, 2021
    • 1 min read

Lipoma Removal Procedure Note

PRE-OP DIAGNOSIS: lipoma POST-OP DIAGNOSIS: Same PROCEDURE: lipoma removal Performing Physician: _ Supervising Physician (if applicable): _ PROCEDURE: Anesthesia: _ 1% _ 2% Lidocaine _ epinephrine Procedure: Timeout procedure was performed prior to initiating procedure to be sure of right patient and right location. The area surrounding the skin lesion was prepared and draped in the usual sterile manner and then was anesthetized. Skin incision was made in a linear fashion and lipoma was excised bluntly using small forceps. Hemostasis was assured. The patient tolerated the procedure well. Closure: _ Monsel’s for hemostasis _ suture (_) _ steri strips _ None Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

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