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.

 
  • venturafamilymed

Rheumatology Review of Systems

Rheumatologic ROS is negative for:

Malar rash, photosensitivity, alopecia, mucosal ulcers, Raynaud's phenomenon, SQ nodules, sense of skin tightening in hands, face or torso, other rashes

No hx of red eyes, photophobia, iritis, uveitis, conjunctivitis, redness or discoloration of sclera, dry eyes or dry mouth

Hx pleurisy, sharp chest pains that increase with deep breath, lung fibrosis, pneumonia, cough phlegm, hemoptysis, DVT, PE

Chest pains, Hx pericarditis, heart murmur

Abdominal pain, nausea, vomiting, diarrhea, constipation, melena, hematochezia, Hx hepatitis, tranfusions or drug use, ulcerative colitis, Crohn's Disease

Hematuria, proteinuria, renal failure, bladder infections, kidney stones, hypertension

Headaches, trouble finding words

Focal weakness, trouble combing hair or getting out of chairs

Burning or tingling in feet

Monocular blindness, dysarthria, dysphagia, seizures or stroke

History of Low WBC, low platelets, anemia

190 views0 comments

Recent Posts

See All

Sleep: _ Interest: _ Guilt: _ Energy: _ Concentration: _ Appetite: _ Psychomotor: _ Suicidality/Homicide: _ Treatment: _ Support: _

_ yo _ w/ _ day h/o of _, nasal sx: _ ear pain: _ ST: _ Cough: _ Fever: _ Rhinorrhea: _ Tx: _ Flu shot: _ Tobacco exposure: _ Sick contacts: _

WWE: _ yo F G_P_ Menarche _ 1. Pap: Last pap: _ Abnormal pap: _ Menses: _ Vaginal complaints: 2. Breast: Last mammo: _ Abnormal mammo: _ Lumps: _ Discharge: _ Family hx breast cancer: _ 3. Bone: