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

Colposcopy & Cryotherapy

Preoperative diagnosis: _

Postoperative diagnosis: same

Procedure: Colposcopy w/ Cryotherapy of Cervix

Surgeon: _ Supervisor: _

Preprocedure counseling: The risks, benefits, and alternatives of the procedure were discussed with the patient.

EBL: 0 ml

Anesthesia: None


Procedure:

Consent and a timeout were performed prior to starting the procedure. The patient was administered 600 mg of ibuprofen PO. The patient was placed in dorsal lithotomy position. The perineum, vulva and vagina were normal. Speculum introduced and cervix identified. The colposcope was advanced. Acetic acid applied x 2 to the cervix.


Lesions identified:

1. _


A test freeze was performed ensuring coverage of entire area as above. The cryotherapy gun was then applied for _ seconds until an ice ball formed with a 5-7 mm border. This was allowed to thaw and then the cryotherapy was again applied for _ seconds to an ice ball of 5-7 mm.


The patient tolerated the procedure well. Return precautions provided. Return to the office in 2-3 weeks for reevaluation.

2,092 views0 comments

Recent Posts

See All

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

Supportive care: Encourage fluids, activity as tolerated, honey for cough, salt water gargles, nasal saline. Tylenol or ibuprofen as needed for discomfort or fever > 102.5 Return if no improvement in

ASQ: Communication: Gross motor: Fine Motor: Problem Solving: Personal-Social: Interpretation / Concern / Plan: Dental assessment performed: No problem suspected, no referral needed Nutritional Assess