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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Femoral Arterial Line 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, sterile gown and sterile gloves throughout the procedure. The _ (L/R) inguinal region was prepped using chlorhexidine scrub and draped in sterile fashion using a three quarter sheet drape and sterile towels. The femoral pulse was identified. Anesthesia was achieved using 1% lidocaine. Palpating the femoral pulse throughout the procedure, the introducer needle was inserted into the femoral artery. Arterial blood was withdrawn. The syringe was removed and a guidewire was advanced through the needle into the femoral artery. The needle was exchanged over the wire for an arterial catheter. The wire was removed and the catheter was secured to the skin using a suture. The patient tolerated the procedure without any hemodynamic compromise. At time of procedure completion, the catheter was connected to the cardiac monitor and calibrated. Appropriate waveform and blood pressure tracing was observed. Estimated blood loss is _.

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