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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Vaccine Visit Note

Subjective: The patient presents today for a vaccine visit. We discussed the pros and cons of the vaccine(s). They have had no prior reaction to vaccines. We discussed possible common reactions. The patient has not been experiencing fever or illness recently. Objective: .vitals Gen: nad Skin – Injection site with no erythema, normal appearing skin Assessment and Plan: The patient tolerated the procedure well. We discussed follow-up precautions including but not limited to injection site redness and swelling, tongue or throat swelling, breathing problems and fever. We discussed thermometer use and OTC meds for symptoms

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