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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Hepatitis C Treatment Visit

HEP C Treatment Visit Dot Phrase. Please read in detail and delete what is not relevant. Do not just copy and paste.


--DELETE EVERYTHING ABOVE HERE--


Clinic Note and Treatment Plan HPI - No H/o Jaundice, GIB, Varices, Encephalopathy, SBP, or Ascites Review of Systems - The Patient relates the following as they may pertain to medication use - No Fatigue, No Headache, No Nausea, No Diarrhea, No Insomnia, No Irritability, No Depression, No Myalgia, No Dizzy episodes Additionally, as noted in HPI plus - CONSTITUTIONAL - NO weight changes, NO fever CARDIOVASCULAR - NO chest pain, NO palpitations RESPIRATORY - NO Cough, NO wheeze, NO SOB GASTROINTESTINAL - NO Dysphagia, NO constipation, NO abdominal pain, NO hematochezia, NO melena, NO hematemesis DERMATOLOGY - NO recent rash, NO pruritus, NO jaundice ENDO/HEME/LYMPH -NO Edema PSYCH/NEUROLOGY - NO current abuse of EtOH or drugs to the severity that would interfere with compliance. PE - GENERAL - A&O x4, NAD HEENT - HNCAT, PERRLA without scleral icterus, neck supple without gland enlargement HEART - RRR S1+S2, no murmurs, rubs, or gallops LUNGS - CTA bilat, AEE bilat, no crackles, wheezes or rhonchi, ABDOMEN - Soft, nontender, BS x4 NA, no organomegaly, no ascites, no r/g EXTREMITIES - no edema, no clubbing DERM - no jaundice, no spider angio, no caput medusa, no abnormal bruising, no ulcers PSYCH - Appropriate mood and affect LABS (INSERT RESULTS WITH DATES) INSERT CREATNINE .heplab HIV (within the last 30 days)

AFP result (if cirrhotic) Fibroscore result Pregnancy test (this visit)

Insert Hep C genotype (and NS5A testing result when applicable) Hepatitis A/B antibody results show immunity OR Prior Hepatitis Vaccinations completed or started - _ DIAGNOSTICS Prior Imaging (within the last 6 months)- needed only if concerned for cirrhosis Assessment/Plan I have verified that patient meets inclusion criteria: Prior Tx with a novel agent (IFN/Ribavirin are OKAY) - NO Cirrhosis – YES OR NO Decompensated (Child-Pugh B/C) = NO - no h/o Varices, Encephalitis, Ascites, Jaundice, or hospitalization for complications of liver disease *If patient has decompensated cirrhosis, or h/o failed prior Tx using a novel agent, the patient will be referred to Hepatology Clinic.

This patient does not have HIV or Hep B co-infection.

**NOTE: If the patient also has HIV, these patients will be staffed and co-managed by Dr. Pawson. Please message Dr. Pawson.

GOLDCOAST: Hepatitis C All Genotypes

Based on the above classification the patient will undergo Treatment with the following:

Compensated Cirrhosis (Child Pugh A) or less: Mavyret x 8 weeks or Epclusa x 12 weeks

1) Medication reconciliation was performed as the above medication is known to interact with several medications including the following – Antiarrhythmics ( Digoxin), Pradaxa, Ethinyl estradiol- containing medications such as combined oral contraceptives, statins including Lovastatin, Atorvastatin, Simvastatin, Anti-Convulsants (carbamazapine), Antimycobacterials (rifampin), HIV Medications, or Herbal Supplements (St John’s Wort). Contraindicated: Amiodarone

Specific to sof/vel: Take sof/vel with food. Take PPI or fast acting antacids 4 hours after taking sof/vel. If on a H2B, take it the same time or 12 hours after taking sof/vel.

Labs and F/u appointments given to patient. Instructions were given on the importance of not missing medication dosage, follow-ups and lab draws. All questions answered. The patient wishes to proceed with treatment and will be scheduled for a Nursing appointment for further information and instructions.

CVS caremark Rx filled out and forwarded to care manager. Next step will be f/u with care manager. Message sent to Jill Chen who will schedule apt. Follow Up Visits and Labs:

Please order HCV Viral load 12 weeks after the patient's end date of medications.

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