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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ADM Outpatient Opiate Detox

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

A/P: Opiate addiction: Discussed options with the patient including finding a methadone clinic vs buprenorphine/naloxone. Pt declines both and would like to detox as an outpt at home. Pt advised that the best option would be inpt detox at a center like Cottage but pt declines. Pt advised on sx of detox including red flag pcx. Pt still opts in for self detox. Side effects and red flags for all meds including hypoT and sx hypoT were d/w pt and pt opts in.

Rx for the following given and explained to pt: #Clonidine 0.1 mg q6 prn w/d sx. HypoT pcx advised. Use for 4 days then stop and observe w/ home BP monitoring for reflex HyperT and Tachycardia. #Immodium 1 tab q6 prn diarrhea #Trazodone 100mg, ½ - 1 tab qhs prn insomnia #5 #Baclofen 10mg TID prn spasms #15 #Zofran 4mg q6 prn nausea #15 #Pt counselled on potential use of Kava Kava and to discuss this with a naturopath or holistic provider to determine if it would be safe to take with the above. Pt advised to seek Whole Foods which may sell it.

Pt to f/u w/ either me or PCP in 4-5 days after cessation for evaluation.

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

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