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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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  • venturafamilymed
    • Sep 3, 2021
    • 1 min read

Endometrial Biopsy (EMB) Procedure Note

PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same PROCEDURE: endometrial biopsy Performing Physician: _ Supervising Physician (if applicable): _ PROCEDURE: A timeout protocol was performed prior to initiating the procedure Bimanual examination was done to determine the position of the uterus. Vaginal speculum was inserted, and the cervix was visualized. The cervix was cleansed with antiseptic solution. The device was inserted through the cervical canal, into the uterine cavity, and up to the fundus. A tenaculum may be placed on the cervix, but usually this is not necessary The depth of the uterus was determined with the instrument The instrument was withdrawn as it was rotated 3-4 times to obtain the sample which was sent in formalin to pathology Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

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