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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Radial Arterial Line 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. After an Allen test was performed to ensure adequate perfusion, the _ (L/R) wrist was prepped using chlorhexidine scrub and draped in sterile fashion using a three quarter sheet drape and sterile towels. The radial pulse was identified and the wrist was positioned in the usual fashion. Anesthesia was achieved using 1% lidocaine. Using the Arrow Radial Arterial Line Kit, a needle was inserted into the radial artery. Arterial blood was seen to pulsate in the flash chamber. The internal guidewire was advanced easily into the radial artery. The catheter was then advanced over the wire and the needle and wire were withdrawn. The catheter was sutured in place. A sterile opsite was placed over the catheter at the insertion site. The patient tolerated the procedure without any hemodynamic compromise. At the time of procedure completion, the catheter was connected to the cardiac monitor and calibrated. Appropriate waveform and blood pressure tracing was observed. Estimated blood loss is _.

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