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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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Intraosseous Line Placement

PROCEDURE NOTE: IO Placement Performed by: [Provider Name] Indication: [IV access required]. [Multiple attempts at peripheral IV placement were made by the nursing staff without success] Consent: [Critical Intervention-unable to obtain] Procedure: The area was prepped in the usual fashion. The [R] [tibia] was cannulated with a [#] gauge IO angiocath. The patient tolerated the procedure well. Post-Procedure Diagnosis: [ ] Complications: [none] Estimated Blood Loss: [minimal] Specimens Removed: [no] Prosthetic devices/implants: [no] Assistant(s): [none]

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Central Line Procedure Note

Central Line Procedure Note Indication: [_] Hypotension/Sepsis/Need for Pressors [_] Vascular Access [_] Dialysis Access [_] Suspected Central Line Infection [_] Line Malfunction [_] Other: _ Central

Exam: Newborn

Gen: healthy appearing newborn in no distress HEENT: no caput or cephalhematoma, normal ears: no pits or tags, nares patent; fontanelles level Eye: Red reflex present & equal Clavicles: no crepitus no

Vasectomy Visit Note

PRE-OP DIAGNOSIS: Desires Elective Sterilization POST-OP DIAGNOSIS: Same PROCEDURE: Elective Bilateral Vasectomy Resident Physician: _ Supervising Physician: _ ANESTHESIA: (select one) _ Marcaine

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