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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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  • venturafamilymed
    • Sep 8, 2021
    • 1 min read

Skin Biopsy Procedure Note

PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same PROCEDURE: skin biopsy Performing Physician: _ Supervising Physician (if applicable): _ PROCEDURE: _ Shave Biopsy _ Excisional Biopsy _ Punch (Size _) The area surrounding the skin lesion was prepared and draped in the usual sterile manner. The lesion was removed in the usual manner by the biopsy method noted above. Hemostasis was assured. The patient tolerated the procedure well. Closure: _ Monsel’s for hemostasis _ suture _ _ None Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

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