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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Endotracheal Intubation Procedure Note

INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _. In Attendance (Y/N)_ CONSENT: [_] During the informed consent discussion regarding the procedure, or treatment, I explained the following to the patient/designee:

a. Nature of the procedure or treatment and who will perform the procedure or treatment.

b. Necessity for procedure and the possible benefits.

c. Risks and complications (most common and serious).

d. Alternative treatments and the risks, benefits and side effects of each (including no treatment).

e. Likelihood of the patient achieving his/her goals without this procedure and surgery treatment.

f. Problems that might occur during the recuperation.

g. Conflicts of interest, if any

[_] The procedure was emergent, the patient was unable to provide consent, and a designee was not immediately available.

PROCEDURE SUMMARY: A time out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, gown and gloves throughout the procedure. The patient was placed on a cardiac monitor including continuous pulse oximetry. Rapid Sequence Intubation was conducted. The patient received _mg of _ for induction and _mg of _ for adequate paralysis. Cricoid pressure was maintained from time induction agent was given to time of cuff balloon inflation. Using a _ laryngoscope and a size _ endotracheal tube with stylet, the patient was intubated on the _ attempt. The stylet was removed and cuff balloon was inflated. Appropriate endotracheal tube position was confirmed by direct visualization of vocal cord passage, fogging of the tube, CO2 colormetric indicator and symmetric breath sounds. The tube was secured at _ cm at the lips. Post intubation chest x-ray is pending at this time.

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