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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

AFMC OBSTETRICAL ULTRASOUND REPORT

Indication: _

Patient Identification: _

Method: _


Report:

The patient was scanned trans-abdominally using the Acuson X150 Ultrasound in the standard fashion. There was a singleton intrauterine fetus noted in a _ position.

Anatomic survey revealed:

-Normal Intracranial anatomy

-Four Chamber heart with FHT at _ BPM

-Normal intra-abdominal anatomy, stomach bubble in left side

-Skin overlying the spine with no evidence of bifida

-Gross motor movement of all four extremities

-Bladder with fluid

-No evidence of hydronephrosis


Fetal Biometry: (all measurements were by Hadlock unless otherwise noted)

-BPD _

-HC _

-AC _

-FL _

-EGA by ultrasound _

-EFW by ultrasound _


Ratios:

-FL/AC _

-HC/AC _

-FL/BPD _

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