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.

 
  • venturafamilymed

ADM Buprenorphine Intake Visit

S:

#Opiates: Pt currently using _. Has been using this for _. How the patient got into this is by _.

Patient uses _ needles. _ used a dirty needle. Last HIV/Hep C was tested _.

Withdrawal sx start about _ hours after use. By _ hours, patient is usually in moderate withdrawal.

DAST tool was completed and screened + for severe substance abuse.

Pt has:

_never tried methadone or buprenorphine/naloxone

_ has tried methadone but was not happy with the tolerability and does not want to use it again.

_ has tried buprenorphine/naloxone and was on _ in the past and well controlled. Obtained it via _

#Meth:

_Pt denies use.

_ Pt acknowledges using _ times per week, or _ times per month.

Method of use is:

_ injection

_ smoking

#MJ:

_Pt denies use.

_ Pt acknowledges using _ times per week, or _ times per month.

#BZDs

_Pt denies use.

_ Pt acknowledges using _ times per week, or _ times per month.

#Barbituates

_Pt denies use.

_ Pt acknowledges using _ times per week, or _ times per month.

#Sedative hypnotics

_Pt denies use.

_ Pt acknowledges using _ times per week, or _ times per month.

#EtOH

_Pt denies use.

_ Pt acknowledges using _ times per week, or _ times per month. Pt states never being drunk to the point of passing out. Pt does not have tremors/shakes or other w/d sx if not drinking and has recently had a timeframe of >1 week of no EtOH w/o sx.

#Tobacco

_Pt denies use.

_ Pt acknowledges using _ per day.

O: Gen: NAD

Skin: NO e/o abscess or cellulitis at this time on evaluation.

A/P:

#Opiate Addiction

Pt educated on the risks/benefits of buprenorphine/naloxone and interactions with other medications and substances. Pt advised that they can not use BZDs while on bup therapy. They must avoid all EtOH use, barbiturate use, and sedative hypnotic use for risk of death. After this discussion pt opts in for buprenorphine treatment. Reading material given. DAST + and pt screened in. Explained to pt the induction process and close follow up including PDMP, UDS, etc. Medication agreement signed. Pt understands that we ware starting buprenorphine with the goal of eventual taper and wean off all opiates and agrees to this plan.

PDMP Cures done today and shows _. It is scanned in the record.

Labs ordered: HIV, Acute hep panel, CMP

_Rx for Suboxone film 4mg #10 given to the patient to hold on to and bring in for induction. Pt advised very clearly that they can not use the films. They need to bring them in unused for in office induction. Pt informed that if they use the film, that is a violation of our agreement and they may no longer be a candidate for treatment here.

_ Rx for Norco _ given to the patient to help pt avoid withdrawal and needing to use other opiates whilst waiting for induction apt. Pt has chronic pain and thus anticipate the norco will help with pain.

Induction will occur on Day 1 at _.

Pt will f/u on day 3 AM at _.

Pt will f/u 1 week later at _. If at that time treatment is stable and consistent, pt may f/u in 1 month.

Pt informed that they NEED to be involved in some sort of substance abuse counselling program. Pt states that they will actively be involved.

Gold Coast NA: 888-817-7425 https://www.gcana.org

Ventura County Behavioral Health Alcohol and Drug Program (ADP): 805-981-9200

Here to Help Program: https://www.suboxone.com/treatment-plan/patient-support

30 minutes spent in interviewing and counselling and discussing the plan and coordinating care.



99 views0 comments

Recent Posts

See All

The patient has been counseled on the procedure as well as risks, benefits, and alternatives. The procedure is considered irreversible and if they desire it to be reversed, it will require a much mo

Supportive care: Encourage fluids, activity as tolerated, honey for cough, salt water gargles, nasal saline. Tylenol or ibuprofen as needed for discomfort or fever > 102.5 Return if no improvement in

ASQ: Communication: Gross motor: Fine Motor: Problem Solving: Personal-Social: Interpretation / Concern / Plan: Dental assessment performed: No problem suspected, no referral needed Nutritional Assess