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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

Incision and Drainage Procedure Note

PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same PROCEDURE: incision and drainage of abscess Performing Physician: _ Supervising Physician (if applicable): _ PROCEDURE: A timeout protocol was performed prior to initiating the procedure. The area was prepared and draped in the usual, sterile manner. The site was anesthetized with _% lidocaine with epinephrine. A linear incision along the local skin lines was made and the purulent material expressed. The abcess was explored thoroughly and sequestered pockets were opened. Bleeding was minimal. Packing: _ Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

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