Type: _ Midline _ Pfannensteil Staples: _ Present _ Removed Subjective: The patient is recently discharged from the hospital and presents for examination of her C-section incision. She notes the usual amount of discomfort and wound discharge. She denies fever, chills, worsening pain or redness. Objective: General: Overall she appears healthy and in no apparent distress. She exhibits the usual difficulty and discomfort moving around postoperatively. Abdomen: It has the normal post-partum appearance and the expected amount of tenderness. It is non-distended, normal active bowel sounds, fundus is firm C/S wound: It is healing nicely with the normal amount of discharge. Staples, if present, were removed and steri-strips were placed. There is no surrounding cellulitis, underlying fluid collections or other evidence of infection. Impression: Recently post C-section, wound healing well Plan: 1. The patient was cautioned to watch for spreading cellulites, recollection of pus, fever, chills, or increased pain. 2. Dressing may be removed once the discharge has ceases, until then change when moist. Do not remove the steri-strips until they are more than half way off. 3. Shower as usual and gently was the area of the incision with soap. 4. Return for 6 week post-partum exam.
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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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