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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Paracentesis Procedure Note

INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N) _ Ultrasound used to mark location: 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 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 area was cleansed and draped in usual sterile fashion using chlorhexidine scrub. Anesthesia was achieved with 1% lidocaine. The _ of the abdomen was prepped and draped in a sterile fashion using chlorhexidine scrub. 1% lidocaine was used to numb the skin, soft tissue and peritoneum. The paracentesis catheter was inserted and advanced with negative pressure until _ colored fluid was aspirated. Approximately 60 mL of ascitic fluid was collected and sent for laboratory analysis. The catheter was then connected to the vaccutainer and _ liters of additional ascitic fluid were drained. The catheter was removed and no leaking was noted. A bandaid was placed over the puncture wound. The patient tolerated the procedure well without any immediate complications. Estimated blood loss was _.

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