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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Well Child Check >12 year old

SUBJECTIVE: _ here for well child check. No parental or patient concerns at this time. Here with parent: _ RISK ASSESSMENT (non-confidential): - Has never fainted before. - No h/o cough, chest pain, or shortness of breath with exercise. - Has never had a significant head injury. - No family history of sudden death while exercising. - No family history of MI or stroke before age 55. RISK ASSESSMENT (confidential): - Home: Safe, peaceful home environment. Family members all get along, more or less. - Education/Employment: School is going _. No problems with safety or bullying at school. - Eating: No concerns about body appearance. Getting sufficient calcium in diet (at least 4 servings per day). No dietary restrictions. - Activities: Enjoys hanging out with friends. Screen time _. Is involved in _ - Drugs: No history of tobacco, EtOH, or drug use. No friends are using these substances. - Safety: No history of violent relationships at home or elsewhere. - Sex: Prefers _. Has not been sexually active (oral or genital) yet. - Suicidality/Mental Health: No concerns. No history of physical or sexual abuse. Sleeps well at night. PM/SH: Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date. OB/GYN HX: Menses started at age _, and is regular. SOCIAL: - No smokers in the home. - No TB or lead risk factors. - Plans after high school: _ IMMUNIZATIONS: - Up to date. OBJECTIVE: - WEIGHT: BMI _ BMI _ %ile - GEN: Normal general appearance. NAD. - HEAD: NCAT. - EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI. - ENMT: TMs and nares normal. MMM. Normal gums, mucosa, palate, OP. Good dentition. - NECK: Supple, with no masses. - CV: RRR, no m/r/g. - LUNGS: CTAB, no w/r/c. - ABD: Soft, NT/ND, NBS, no masses or organomegaly. - GU: Normal genitalia, Tanner stage _ - SKIN: WWP. No skin rashes or abnormal lesions. - MSK: No deformities or signs of scoliosis. Normal gait. No clubbing, cyanosis, or edema. - NEURO: Normal muscle strength and tone. No focal deficits. LABS/STUDIES: - Urine dip normal. - Hearing screen normal. - Snellen testing: _ ASSESSMENT/PLAN: * Healthy _ yo adolescent - CBC ordered. No indication for DM screening. - Check lipid panel 9-11 yo & 17 - 21 yo (universal rec) - Check HIV 15-18 yo, repeat PRN thereafter - Screen for depression yearly > 12 yo PHQ2: _ - Follow in one year, or sooner PRN. - ER/return precautions discussed. * Vaccines today: - Influenza, HPV (0, 1-2, and 6 months, > 9 yo), Tdap (11-12), Meningococcal ACWY (11-12, boost 16 yo), Men B (16-23, or > 10 w/ incr risk) * Anticipatory guidance (discussed or covered in a handout given to the family) - Confidentiality of visit documentation. - Puberty, sex, abstinence, safe dating. - Avoiding tobacco, drugs, alcohol; and never getting into a car with someone under the influence. - Dealing with stress. - Discipline and role models. - Seat belts, helmets and safety gear, sunscreen - Internet safety, limiting screen time - Importance of daily exercise. - Obesity prevention and adequate calcium. - Good dental hygiene. - Eliminating guns from the home, or locking bullets separately

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