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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Thoracentesis 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 and the chest x-ray was reviewed, the appropriate side was confirmed and marked. 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 prepped and draped in a sterile manner using chlorhexidine scrub after the appropriate level was percussed and confirmed by ultrasound. 1% lidocaine was used to anesthesize the skin, subcutaneous tissue, superior aspect of the rib periosteum and parietal pleura. A finder needle was then introduced over the superior aspect of the rib to locate the pleural fluid; _ colored fluid was aspirated at a depth of approximately _ cm. A 10-blade scalpel was used to nick the skin at the insertion site. The Safe-t-Centesis needle was then introduced through the skin incision into the pleural space using negative aspiration pressure and the red colormetric indicator to confirm appropriate positioning of the needle. The thoracentesis catheter was then threaded without difficulty. _ ml of _ colored fluid was removed without difficulty. The catheter was then removed. No immediate complications were noted during the procedure. A post-procedure chest x-ray is pending at the time of this note. The fluid will be sent for studies. Estimated blood loss is _.

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