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

Subclavian Central Line Procedure Note

INDICATION:_ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N) _ Ultrasound Used: 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: The CDC Central Line Insertion Practices form was completed by an independent observer (_) starting with the first handwash prior to starting sterile technique. 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 patient was placed in Trendelenburg position. The _ chest region was prepped using chlorhexidine scrub and draped in sterile fashion using a full drape and sterile probe cover and sterile gel employed. Anesthesia was achieved with 1% lidocaine. The introducer needle was inserted approximately two centimeters lateral to and 1 cm inferior to the normal curvature of the patient's clavicle. Venous blood was withdrawn. The syringe was removed and a guidewire was advanced into the introducer needle. A small incision was made at the skin surface with a scalpel and the introducer needle was exchanged for a dilator over the guidewire. After appropriate dilation was obtained, the dilator was exchanged over the wire for a _ central venous catheter. The wire was removed and the catheter was sutured in place at _ cm. A sterile sorbaview shield was placed over the catheter at the insertion site. The patient tolerated the procedure without any hemodynamic compromise. At time of procedure completion, all ports aspirated and flushed properly. Post-procedure chest x-ray is pending at this time. Estimated blood loss is _.

293 views0 comments

Recent Posts

See All

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

PRE-OP DIAGNOSIS: Desires Elective Sterilization POST-OP DIAGNOSIS: Same PROCEDURE: Elective Bilateral Vasectomy Resident Physician: _ Supervising Physician: _ ANESTHESIA: (select one) _ Marcaine

PROCEDURE NOTE: IV Placement under Ultrasound Guidance Performed by: [Provider Name] Indication: [IV access required. Multiple attempts at peripheral IV placement were made by the nursing staff withou