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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Vasectomy Visit Note

PRE-OP DIAGNOSIS: Desires Elective Sterilization POST-OP DIAGNOSIS: Same PROCEDURE: Elective Bilateral Vasectomy Resident Physician: _ Supervising Physician: _ ANESTHESIA: (select one) _ Marcaine 0.5% or _Lidocaine 1% Total amount used: _ mL INDICATIONS: This gentleman desires elective sterilization. He was counseled regarding the risks, alternatives, and benefits of male sterilization by vasectomy. He was informed of the risks of the procedure, including but not limited to failure of the procedure to produce sterility, the risks of bleeding, infection, and injury to scrotal contents. All questions were answered in the pre-vasectomy conference and the required State of California consent form was signed. No guarantees were given or implied. A time out was taken prior to the procedure. PROCEDURE: The patient was laid supine on the procedure table. He was sterilely prepped and draped in the usual fashion. The vasa were identified bilaterally. The left vas was grasped using the three-finger technique. Local anesthesia with a 27 gauge needle was applied to the skin in the (select one) _ midline / _ lateral scrotum and to the left vas and surrounding tissue. A vas fixing forcep was used to grasp the vas through the scrotal skin. A vas dissecting instrument was then used to pierce the skin and down through the fascia. The vas was then identified and delivered through the incision. The surrounding vassal tissue was incised in the midline in a vertical fashion to reveal the vas. The vas was grasped with a vas forcep and delivered out of the fascia. The vas was distally and proximally grasped. (select one) _ Method 1: The intervening segment of approximately 2 cm was excised and sent for pathologic review. The lumen of the vas were sealed with thermal fine wire cautery. The proximal vas was then closed over with fascia in a fascial interposition technique. _ Method 2: Small surgical clips were placed on the distal and proximal ends of the vas and. and the intervening segment of approximately 2 cm was excised. The right vas was attended to in the same fashion as the left vas after local anesthesia was applied to the vas and surrounding tissue. All bleeding was controlled. The scrotal fascia was (select one) _ allowed to close by primary intention / _ closed with 4-0 vicryl. Sterile dressings were applied and the patient was sent home with standard post-vasectomy instructions, including instructions to return with a semen sample for analysis after 15-20 ejaculations.

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