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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Chest Tube 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. PROCEDURE SUMMARY: A time out was performed and after the chest x-ray was reviewed, the appropriate side was confirmed and marked. 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 patient was prepped and draped in a sterile manner using chlorhexidine scrub after the patient was positioned in the usual fashion. A total of _ ml of 1% lidocaine was used to anesthesize the skin, subcutaneous tissue, superior aspect of the rib periosteum and parietal pleura. A 2 cm incision was then made parallel to the rib in the midaxillary line at the level of the _ rib. The subcutaneous tissue superficial and superior to the rib was dissected bluntly to the level of the pleura. The pleura was then entered bluntly. _ was noted from the pleural space. The disruption in the parietal pleura was expanded bluntly and a finger was inserted and swept carefully in all directions. A _ French chest tube was then inserted using my finger as a guide. The chest tube was directed _ and inserted easily. The chest tube was sutured to the skin at the insertion site, and connected securely with tape to a pleurovac. A sterile occlusive dressing was placed over the insertion site. No immediate complications were noted. A post-procedure chest x-ray is pending at the time of this note. Estimated blood loss is _.

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