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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IUD Intrauterine Device Insertion Procedure Note

PRE-OP DIAGNOSIS: desired long-term, reversible contraception POST-OP DIAGNOSIS: Same PROCEDURE: IUD placement Performing Physician: _ Supervising Physician (if applicable): _ Checklist: Multiple Partners [_] Yes [_] No Dysmenorrhea [_] Yes [_] No Copper Allergy [_] Yes [_] No PID/STD [_] Yes [_] No Ectopic Pregnancy [_] Yes [_] No Breastfeeding [_] Yes [_] No IUD type: [_] Mirena ® [_] Paraguard ® [_] Skyla ® [_] Kyleena ® PROCEDURE: Timeout procedure was performed to ensure right patient and right site. A bimanual exam was performed to determine the position of the uterus. The speculum was placed. The vagina and cervix was sterilized in the usual manner and sterile technique was maintained throughout the course of the procedure. A single toothed tenaculum was applied to the anterior lip of the cervix and gentle traction applied to straighten and stabilize it. The depth of the uterus was sounded to be of appropriate depth (usually 6.5 to 8.5cm). With gentle traction on the tenaculum, the IUD was inserted to the appropriate depth and deposited by withdrawing on the insertion tube holding the rod steady. The string was cut to an estimated 4 cm length. Bleeding was minimal. The patient tolerated the procedure well. Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

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