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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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Health Maintenance: Male over 65

Healthcare maintenance for male greater 65 years of age (with life expectancy >10 years) Box ([_]) checked if maintenance item performed at this visit. Cardiovascular disease: Per 2007 USPSTF Blood Pressure Screening Guidelines and JNC-8 BP screen/control performed today: [_] Next screen due in 2 years as BP <120/80 [_] Next screen due in 1 year as BP <150/90 [_] See HTN plan above Dyslipidemia: Per 2008 USPSTF Lipid Disorders Screening Guidelines (Grade A) I discussed the risks and benefits of lipid screening with the patient. [_] Patient is 35 or older and has elected to undergo lipid screen [_] Screening recommended, patient declines screening [_] No risk factors present, screening not indicated Patient’s ASCVD risk score is _ per 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol [_] no further interventions required [_] See plan above Weight Control: Per 2012 USPSTF Obesity Screening Guidelines (Grade B) and ACC/AHA BMI screening performed today [_] Patient BMI < 18.5, see underweight plan above [_] Patient BMI WNL, discussed ACC/AHA diet and exercise recommendations to maintain weight [_] Patient BMI 25 or greater, see overweight plan above [_] Patient’s BMI >25 and CVD risk factors (HTN, HLD, DM, personal or family history) or >30, see obesity plan above Diabetes: 2008 USPSTF Type 2 Diabetes Mellitus Screening Guidelines (Grade B) Indication: Asymptomatic adult with sustained blood pressure >135/80 (treated or untreated) 2014 ADA Standards of Medical Care Screening Guidelines Indication: Patient is >45 years of age Based on the above risk factors: [_] Screening indicated, patient elects to be screened for diabetes with a hemoglobin A1C [_] Patient with evidence of pre-diabetes and will be screened yearly [_] Patient without evidence of pre-diabetes and will be screened every 3 years [_] Screening indicated, patient declines screening Colorectal Cancer: Per 2008 USPSTF Colorectal Cancer Screening Guidelines (Grade A/C) Indication: Patient is <75 (Grade A) Indication: Patient is 76-85 and has risk factors and has a reasonable life expectancy > 10 years (Grade C) [_] We discussed, colonoscopy (associated with 271 life-years gained for every 1000 persons screened, Hemoccult II and flexible sigmoidoscopy (218 and 199 life-years gained, respectively, per 1000 persons screened). [_] Patient elects to undergo colonoscopy every 10 years [_] Patient elects to undergo flexible sigmoidoscopy every 5 years [_] Patient elects to undergo yearly FOBT/Hemoccult screening [_] Patient declines screening [_] Lung Cancer: Per 2013 USPSTF Lung Cancer Screening Guidelines Indication: Patient is <80 years of age with 30 pack-year smoking history and currently smoke or have quit within the past 15 years [_] We discussed the risks and benefits of low-dose CT. [_] I rec'd low-dose CT based on the 20% reduction in lung cancer mortality with screening (NNT 5), and all cause mortality of 6.7% (NNT 15) based on the NLST randomized trial. [_] We discussed the potential harms of screening including high rates of "false-positive" (non-cancer) findings leading to additional testing (usually serial imaging), which may include invasive procedures. [_] Will continue with annual screening until the patient has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery. [_] Patient elects for annual screen, next screening due:_ [_] Patient declines screening Abdominal Aortic Aneurism: Per 2014 USPSTF AAA Screening Guidelines (Grade B) Indication: Patient is between 65 and 75 years of age with a past or current history of smoking, or with a family history of AAA (Grade B) [_] We discussed the risks and benefits of screening. [_] We discussed the current available literature regarding screening. According to the 2007 Cochrane meta-analysis of available RCT data (Chichester, Viborg, Western Australia, MASS) in men who are ages 65 to 75 and who have ever smoked who underwent screening ultrasound. Three to five years after screening there was no significant difference in all-cause mortality between screened and unscreened groups. There was an absolute benefit for AAA related mortality (OR 0.60, AR 0.1%, NNT 915), and benefit for reduction in ruptured AAA (OR 0.45, AR 0.3%, NNT 215). The rate of surgery was increased in the screening group. (OR 2.03, AR 0.4%, NNT 209). The largest RCT (MASS) conducted a 13 year follow up period in which benefits for AAA related mortality improved. (HR 0.58, AR 0.4%, NNT 216). [_] The patient elects to undergo screening [_] The patient would prefer to defer screening at this time Vaccines: Per CDC Guidelines Seasonal influenza: Recommended for all patients Td/Tdap (1 dose every 10 years, can be administered regardless of interval) Zoster Pneumococcal vaccine: Per ACIP Guidelines, PCV13 followed at least 6-12 months later by PPSV23 (or vice versa). Hepatitis A: Indication: Patient with risk factors (MSM, IVDU, chronic liver disease or receive clotting factor concentrates, working with HAV-infected primates or with HAV in a research laboratory setting, travel to high or intermediate endemicity of hepatitis A, close personal contact (eg, household or regular babysitting) with an international adoptee during the first 60 days after arrival in the United States from a country with high or intermediate endemicity) Hepatitis B: Indication: Patient with risk factors (Sexually active with >1 partner during the previous 6 months, seeking evaluation or treatment for a STD, IVDU, MSM, Healthcare personnel and public safety workers, DM, end-stage renal disease, HIV, and/or chronic liver disease) Meningococcal (two doses at least two months apart due) Indication: Patient with risk factors (anatomical or functional asplenia, or persistent complement component deficiencies. Booster rec’d every five years is recommended for adults previously vaccinated who remain at increased risk for infection as above, patient due [_] Patient elects for the following vaccines: _ [_] Patient declines the following vaccines: _ STD: Per USPSTF Screening Guidelines Indication: Patient without risk factors, no further testing indicated Indication: Patient with risk factors (MSM, IVDU, multiple partners, or seeking STD screening/treatment) [_] Patient elects to be screened for: [_] GC/Chlamydia, HIV, and Hepatitis B, for risk factors listed above [_] Syphilis, for risk factors (commercial sex worker and/or person in correctional facilities) [_] Patient declines screening HIV: Per 2013 USPSTF HIV Infection Screening Guidelines (Grade A) Indication: All low risk adults should receive 1 HIV screen during their lifetime. For patient with high risk sexual activity see above STD screening recommendations. [_] Patient elects to be screened today [_] Patient declines screening Hepatitis C: Per 2013 USPSTF Hepatitis C Screening Guidelines (Grade B) Screening indicated for patient based on the following risk factors; -history of illicit injection drug use or intranasal cocaine use, even if only used once -received clotting factors made before 1987 -received blood/organs before July 1992 -received blood from a donor who later tested positive for HCV -born to HCV-infected mother -needle stick injury or mucosal exposure to HCV-positive blood -current sexual partner of an HCV-infected person -liver disease (persistently elevated alanine aminotransferase [ALT] level) -born in the United States between 1945 and 1965 -chronic hemodialysis -HIV -Incarcerated [_] We discussed the risks and benefits of screening. [_] I rec'd screening based on the all-cause mortality reduction, decrease in rates of progression to chronic liver disease, and hepatocellular carcinoma in patients with sustained serologic response to antiviral treatment. [_] We discussed the risk of screening, including false positives which may lead to unnecessary liver biopsy or treatment with antivirals. [_] Patient without ongoing risk factors and therefore elects to be screened only once [_] Patient with ongoing risk factors and elects to be screened annually or sooner as needed [_] Patient declines screening Prostate Cancer: Per 2012 USPSTF Prostate Cancer Screening Guidelines (Grade D), AAFP Guidelines, ACS Guidelines, and AUA Guidelines [_] Patient counseled on pros/cons of PSA screening in adults. Advised on differing opinions of USPSTF/AAFP (against routine screening) vs ACS/AUA (for routine screening). Pt understands risk of false + and w/u as well as missing it if not screened. [_] Patient opts in for screening [_] Patient opts out for screening Psycho-social: [_] Patient without evidence of or risk factors for depression, anxiety, alcohol, tobacco, or domestic abuse [_] Patient screened positive, see above for plan

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