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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Newborn Admit Note H&P

CC: Newborn HPI Newborn baby _ born to a _ yo G_P_ at _ and _/_ weeks EGA who presented in _ labor with/without SROM at _/_/_. Total time with ruptured membranes was _. She was (not) induced/augmented and progressed well to complete over about _ hours. Patient then began to push, and at this time of 2nd stage of labor had _ complications. She delivered a vigorous baby in _ position via vaginal delivery. There was _ nuchal cord reduced by _. Baby was immediately placed on mother’s abdomen and cord was clamped after _ minutes. Baby with _ cry and APGARS at 1 and 5 minutes of _ and _, respectively. Maternal Prenatal Hx: ABO/Rh: _ Antibody: _ Hgb: _ Pap: _ Rubella: _ Varicella: _ VDRL: _ Urine Cx: _ HBsAg: _ HIV: _ CT: _ NG: _ MSAFP: _ 1 hr GTT: _ GBS: _ PPD: _ Pregnancy Complications: _ Pertinent Family History: _ Physical Exam .vitals .birthweight GEN: NAD HEENT: Red Reflex seen b/l, external ears w/o tags or pits, AFOF, + molding, No cephalohematoma, hard palate intact NECK: Negative clavicular fx CV: RRR, no MRG RESP: CTAB, no distress ABD: nl BS, soft, nd, no masses, no guarding RECTAL: Patent, no masses GU: Normal female genitalia for newborn, patent urethra and vagina PULSES: 2+ femoral pulses b/l EXTR: No swelling or edema in the BLE, No acrocyanosis, Negative Ortoloni and Barlo b/l SKIN: No rashes or lesions thorughout body, no spinal tufts of hair or dimples, No Jaundice NEURO: MAEE, good tone, +Morro, +Grip in all four extremities, +Galant b/l Assessment and Plan: DOL#_ for this _ and _/_ week EGA _ born via _ complicated by _ to a _ yo G_P_->_ mom who is _ (blood type) and Antibody _ with prenatal course that was complicated by _ and normal PNL except _ with adequate/inadequate intrapartum prophylaxis. Maternal Blood type _: (Do not) send cord blood for HDN w/u Breast Feed on demand with support as needed Hepatitis B Vaccination: Give _ State NBS per routine, CHD screen per routine, Hearing Screen per routine Routine couplet care otherwise.

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ASQ: Communication: Gross motor: Fine Motor: Problem Solving: Personal-Social: Interpretation / Concern / Plan: Dental assessment performed: No problem suspected, no referral needed Nutritional Assess

BMI _ % Gen: NAD, age appropriate. ENT: TM clear, nares clear, pharynx clear Lymph: No cervical lymphadenopathy Endo: Normal thyroid CVS: RRR, nml PMI, no M/R/G Pul: CTA, no W/R/R, no fremitus Abd: +B

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