top of page

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.

  • venturafamilymed

CHDP Required Elements

ASQ:

Communication:

Gross motor:

Fine Motor:

Problem Solving:

Personal-Social:

Interpretation / Concern / Plan:

Dental assessment performed: No problem suspected, no referral needed

Nutritional Assessment Performed: No problem suspected, no referral needed

Age appropriate anticipatory guidance was reviewed: No problem suspected

Age appropriate developmental assessment was performed: No problem suspected

Age appropriate vision and hearing assessed: No problem suspected

Age appropriate Hgb and Hct assessed: No intervention needed

Lead exposure evaluated: No problem suspected

Urinalysis: No problem suspected or Not indicated

TB risk assessed: No need for intervention

BMI Percentile: _%ile

Smoking:

- Second hand smoke exposure: Yes [_] No [_]

- The patient uses tobacco: Yes [_] No [_]

- The patient/parent was counseled about risks of tobacco use: Yes [_] No [_]

The patient is enrolled in WIC: : Yes [_] No [_]

- If yes, Ht. Wt. and Hgb and Hct checked

Vaccines: Vaccination status was evaluated. Age appropriate vaccines were recommended as follows: as above

Follow Up is recommended in _ months.

706 views0 comments

Recent Posts

See All

Initial Medicare Annual Wellness Visit Checklist

HPI/Family /Social History Perform patient reported Health Risk Assessment Staying Healthy Assessment – Senior version Medical and Family History – By history – often in Cerner Current Providers List

Disability Template

Date first seen for this problem: _ Date completing form: _ Treatment Intervals: [_] Daily [_] Weekly [_] Monthly [_] as needed. Date first incapable of work: _ Anticipated Release date to return to w

Vasectomy Consent

The patient has been counseled on the procedure as well as risks, benefits, and alternatives. The procedure is considered irreversible and if they desire it to be reversed, it will require a much mo

bottom of page