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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Neonatal Circumcision Procedure Note

Preoperative diagnosis: Desires Neonatal Circumcision Postoperative diagnosis: same Procedure: Neonatal Circumcision Operator(s): _ Preprocedure counseling: The risks, benefits, and alternatives of the procedure were discussed with the patient's parent/guardian. Procedure: A timeout was performed prior to starting the procedure. The infant was laid in a supine position and the surgical field was prepped and draped in usual sterile fashion. A pacifier with sucrose water was used to aid anesthesia. _ mL of 1% lidocaine without epinephrine was used to anesthetize the penis with a (select one) _ dorsal penile nerve block / _ subcutaneous ring block. A dorsal slit was made after clamping the foreskin. The foreskin was retracted and adhesions were removed bluntly. The _ cm Gomco clamp was placed in usual fashion ensuring the dorsal slit was completely included and that the amount of foreskin was symmetric on all sides. After securing the Gomco clamp to ensure hemostasis, the foreskin was cut with a scalpel. The Gomco clamp was removed. Hemostasis was assured. The wound was dressed with 1/2” petrolatum gauze. The attending physician, Dr. _, was present throughout the entire procedure.

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