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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Brachial Arterial Line Procedure Note

INDICATION: _

PROCEDURE OPERATOR: _

ATTENDING PHYSICIAN: _ In Attendance (Y/N)_

CONSENT:

Consent was obtained from _ prior to the procedure. Indications, risks, and benefits were explained at length.

The procedure was performed emergently and the permission was implied because of the emergent nature.

PROCEDURE SUMMARY:

A time out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, sterile gown and sterile gloves throughout the procedure. The _ (L/R) arm was prepped using chlorhexidine scrub and draped in sterile fashion using a three quarter sheet drape and sterile towels. The brachial pulse was identified by ultrasound. Anesthesia was achieved using 1% lidocaine. Using out of plane ultrasound guidance, a needle attached to a syringe, was inserted into the brachial artery with constant negative aspiration pressure. Arterial blood was seen to pulsate in the syringe. The syringe was removed and a guidewire was advanced easily into the brachial artery. The catheter was then advanced over the wire and the needle and wire were withdrawn. The catheter was sutured in place. A sterile opsite was placed over the catheter at the insertion site. The patient tolerated the procedure without any hemodynamic compromise. At the time of procedure completion, the catheter was connected to the cardiac monitor and calibrated. Appropriate waveform and blood pressure tracing was observed. Estimated blood loss is _.

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