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: 15 month old

SUBJECTIVE:

_-month old _ here for well child check. No parental concerns at this time.

REVIEW OF SYSTEMS:

- Diet: No concerns.

- Voiding/stooling: No concerns.

- Sleeping: Has regular bedtime routine, and sleeps through the night without feeding.

- Behavior: No concerns.

- Activity: Screen/TV time is limited to < 2 hrs/day.

PM/SH:

Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date.

DEVELOPMENT:

- Gross motor: Walking, starting to run, bends down without falling.

- Fine motor: Feeds self with a spoon, puts blocks in a cup, drinks from a cup with very little spilling.

- Cognitive: Follows simple directions, scribbles.

- Social/Emotional: Pretend play (e.g. phone), stranger anxiety, likes to copy older children and adults, tries to help.

- Communication: Knows at least 4 words, points to body parts, brings toys over to show you.

SOCIAL:

- No smokers in the home.

- No major social stressors at home.

- No safety concerns in the home.

- Daytime child care is with _

- No TB or lead risk factors.

IMMUNIZATIONS:

- Up to date.

OBJECTIVE:

- VITALS: _

- GEN: Normal general appearance. NAD.

- HEAD: NCAT.

- EYES: PERRL, red reflex present bilaterally. Light reflex symmetric. EOMI, with no strabismus.

- ENMT: TMs, nares, and OP normal. MMM. Normal gums, mucosa, palate. 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 _male genitalia. Testes descended bilaterally.

- SKIN: WWP. No skin rashes or abnormal lesions.

- MSK: Normal extremities & spine.

- NEURO: Normal muscle strength and tone. No focal deficits.

GROWTH CHART: Following growth curve well in all parameters.

ASSESSMENT/PLAN:

* Healthy _-month old toddler

- The family was given a children’s book today (per “Reach Out and Read” program).

- The family was given a list of dentists in the county who take MediCal.

- CBC and lead level ordered.

- Follow up at 18 months of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- DTaP #4, Influenza

- Pentacel #4 (DTaP, IPV, Hib), Influenza

* Anticipatory guidance (discussed or covered in a handout given to the family)

- Common immunization SE’s

- Safety: Child-proofed home, burn prevention, kitchen safety, water safety, firearms, sunscreen, Poison Control number (800-222-1222)

- Car seat facing backward until 2 year of age and 20 pounds

- Dental care and fluoride; dental visits

- Food: Picky eating, fortified whole milk, limiting juice and junk/fast food.

- Transitioning from bottle to cups; no bottle in bed

- Discipline: Praising wanted behaviors, distraction, setting limits, routines.

- Emerging independence (offer choices)

- Speech development (importance of reading and talking)

- Sleep: Nightmares, sleep hygiene

- Limiting screen time

- Hazards of second hand smoke

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