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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Lumbar Puncture Procedure Note

INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N): _ CONSENT:

[_] During the informed consent discussion regarding the procedure, or treatment, I explained the following to the patient/designee:

a. Nature of the procedure or treatment and who will perform the procedure or treatment.

b. Necessity for procedure and the possible benefits.

c. Risks and complications (most common and serious).

d. Alternative treatments and the risks, benefits and side effects of each (including no treatment).

e. Likelihood of the patient achieving his/her goals without this procedure and surgery treatment.

f. Problems that might occur during the recuperation.

g. Conflicts of interest, if any


[_] The procedure was emergent, the patient was unable to provide consent, and a designee was not immediately available. PROCEDURE SUMMARY: A time-out was performed. My hands were washed immediately prior to the procedure. I wore a surgical cap, mask with protective eyewear, sterile gown and sterile gloves throughout the procedure. The patient was placed in the _ position with help from the nursing staff. The area was cleansed and draped in usual sterile fashion using betadine scrub. Anesthesia was achieved with 1% lidocaine. A 20-gauge 3.5-inch spinal needle was placed in the _ lumbar interspace. On the _ attempt, _ colored cerebral spinal fluid was obtained. The opening pressure was _ cm H20. CSF was collected into 4 tubes. These were sent for the usual tests, including 1 tube to be held for further analysis if needed. A sterile bandaid was placed over the puncture site. The patient had no immediate complications and tolerated the procedure well. Estimated blood loss was _.

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