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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
    • Aug 26, 2021
    • 1 min read

ADM Buprenorphine Induction Visit

S: Pt presents for bup induction. Pt feels to be in moderate w/d. Pt c/o cramps, sweats, chills, goose bumps, anxiety, and joint pains. Has not used anything since _

O:

Gen: Anxious and fidgety.

See VSS above

See scanned COWS sheet for details

A/P:

Induction:

- Dosing today (day 1): Please see scanned dosing record. End dose for today is _ mg to be used _. Pt may use 4 mg at night if they feel w/d sx.

Pt to f/u day 3 AM at _ to determine maintenance dose.

20 minutes spent in interviewing and counselling and discussing the plan and coordinating care.

Pt informed that they NEED to be involved in some sort of substance abuse counselling program. Pt states that they will actively be involved.

Gold Coast NA: 888-817-7425 https://www.gcana.org

Ventura County Behavioral Health Alcohol and Drug Program (ADP): 805-981-9200

Here to Help Program: https://www.suboxone.com/treatment-plan/patient-support



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