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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Joint Injection Procedure Note

PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same PROCEDURE: joint injection Performing Physician: _ Supervising Physician (if applicable): _ Lot # _ Dose: _ 1% _ 2% Lidocaine _ mL _ Steroid 40mg/mL Triamcinolone acetonide Exp _ Procedure: The area was prepped in the usual sterile manner. The needle was inserted into the affected area and the steroid was injected. There were no complications during this procedure. Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

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