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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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Central Line Procedure Note

Central Line Procedure Note

Indication:

[_] Hypotension/Sepsis/Need for Pressors

[_] Vascular Access

[_] Dialysis Access

[_] Suspected Central Line Infection

[_] Line Malfunction

[_] Other: _

Central Line Location: [_] Right or [_] Left

[_] Internal Jugular Vein or [_] Subclavian Vein or [_] Femoral Vein

Procedure Operator: _

Attending Physician: _

Present During Procedure?: [_] Yes [_] No

Consent:

[_] Consent was obtained from _ prior to the procedure. Indications, risks and benefits were discussed prior to the procedure.

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

Doctors _ and _ confirmed the emergent nature of the procedure and signed consent form prior to the procedure.

PROCEDURE SUMMARY:

The CDC Central Line Insertion Practices form was completed by _ during and immediately following the procedure. A time out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, full gown and sterile gloves throughout the procedure. The patient was placed in Trendelenburg position. The [_] Left [_]Right [_] neck [_] chest [_] groin was prepped using [_] chlorhexidine scrub (or [_] other: why _) and draped in sterile fashion using a three quarter sheet drape and sterile towels. Skin preparation was allowed to dry prior to skin puncture. Anatomic landmarks were identified. Anesthesia was achieved over the vein using 1% lidocaine. Using real-time ultrasound, with sterile probe cover and sterile gel, the introducer needle was inserted into the vein under direct ultrasound visualization. Venous blood was withdrawn. The syringe was removed and a guidewire was advanced into the introducer needle. The guidewire was visualized in the appropriate vein by ultrasound. A small incision was made at the skin surface with a scalpel and the introducer needle was exchanged for a dilator over the guidewire. After appropriate dilation was obtained, the dilator was exchanged over the wire for an [antimicrobial coated] _ central venous catheter. The wire was removed and the catheter was sutured in place at _ cm. A biopatch was placed at the insertion site. A sterile op-site was placed over the catheter and biopatch. The patient tolerated the procedure without any hemodynamic compromise. At time of procedure completion, all ports aspirated and flushed properly.

Post-procedure chest x-ray :

[_] Is pending at this time.

[_] Shows adequate positioning of the catheter for use.

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