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.

Exam: Sports Physical

venturafamilymed
Sep 8, 2021
1 min read

BMI _ %

Gen: NAD, age appropriate.

ENT: TM clear, nares clear, pharynx clear

Lymph: No cervical lymphadenopathy

Endo: Normal thyroid

CVS: RRR, nml PMI, no M/R/G

Pul: CTA, no W/R/R, no fremitus

Abd: +BS, soft, NT, ND

GU: normal penis, testicles. No hernia. Tanner: _

Ext: no C/C/E

Psych: affect normal

Skin: acne_ Tinea pedis _

MSK:

Strength:

Upper extremity:

Right: Deltoid 5/5 Biceps 5/5 Triceps 5/5 Wrist flex 5/5 Wrist ext 5/5 Interossei 5/5 Thenar 5/5

Left: Deltoid 5/5 Biceps 5/5 Triceps 5/5 Wrist flex 5/5 Wrist ext 5/5 Interossei 5/5 Thenar 5/5

Lower Extremity:

Right: HF: 5/5 Q: 5/5 H: 5/5 PF: 5/5 EHL: 5/5

Left: HF: 5/5 Q: 5/5 H: 5/5 PF: 5/5 EHL: 5/5

Neuro: DTR:

Left: L3/4: 2/4 S1: 2/4

Right: L3/4: 2/4 S1: 2/4

Neuro: Neg rhomberg, intact finger nose

No Vision Test results this visit.

1 Comment

Top care Emergency Room

Mar 18

Clear and concise sports physical documentation! It’s great to see such a thorough and structured evaluation ensuring athlete safety and readiness. For any sudden injuries or urgent concerns, a 24 Hour Emergency Room in Houston Heights provides fast and dependable care when needed.