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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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PROCEDURE NOTE: Procedural Sedation

Performed by: [Provider Name]


Indications: [ ]

Universal Protocol: a time out was performed and the correct patient and site were verified

Consent: The risks and benefits of monitored anesthesia care, including the risk of aspiration, deep sedation requiring airway management including possible intubation, nausea/vomiting and the risks of not performing the procedure, including severe pain and inability to complete the procedure, were all discussed with the [patient]. The alternatives of performing the procedure, including local anesthesia and IV analgesia, also discussed. The patient has a ride home available.

ASA Class: [I-healthy / II-mild systemic disease / III-severe systemic disease / IV-incapacitating systemic disease]

Mallampati Score: _

Pre-anesthesia evaluation, including history, exam, and informed consent is documented in the note above.

Monitoring: Continuous monitoring of heart rate, respiratory rate, pulse oximetry and ETCO2. Supplemental oxygen prior to and during procedure via nasal cannula. Resuscitation equipment available at the bedside during sedation.

Intra-service start time: [00:00]

Intra-service stop time: [00:00]

The patient received [ ] and dosages were recorded on the sedation form. The patient was recovered from the sedation without complication or incident. Patient returned to pre-sedation level of awareness. The monitoring was discontinued at this time.

Post-anesthesia evaluation:

Respiratory function, cardiovascular function, temperature, and mental status [did/did not] return to pre-anesthetic state.

Pain [was/was not] controlled.

The patient [did/did not] tolerate p.o.

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