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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 8, 2021
    • 1 min read

Exam: Newborn

Gen: healthy appearing newborn in no distress

HEENT: no caput or cephalhematoma, normal ears: no pits or tags, nares patent; fontanelles level

Eye: Red reflex present & equal

Clavicles: no crepitus noted

Mouth: Lip and palate intact, good suck

Pul: CTA Bilateral, no W/R/R

CVS: RRR, normal S1/S2. no murmur/rub/gallop

MSK: Good muscle tone, Neg Barlow, neg Ortolani

Abdomen: Soft without organomegaly or masses noted, umbilicus clean and dry

Back: Normal spine without significant sacral dimple.

Vasc: Femoral Pulse: Present and palpable equal bilaterally

Anus: Patent

Genitalia: Normal __male.

Skin: No rashes noted. Minimal sacral melanocytosis

Neuro: Intact moro, suck, and grasp, toes upgoing bilaterally

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