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.

 
  • venturafamilymed

Well Child Check: 18 month old

SUBJECTIVE:

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

REVIEW OF SYSTEMS:

- Diet: No concerns. Weaned from bottle.

- Voiding/stooling: No concerns. + showing interest in potty.

- 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: Runs, walks up steps, able to kick a ball.

- Fine motor: Feeds self with a spoon, removes clothes, stacks 2 blocks, uses spoon and cup

without spilling most of the time.

- Cognitive: Follows simple directions, scribbles, knows name of favorite book.

- Social/Emotional: Helps in the house, laughs in response to others, points out things of interest.

- Communication: Knows at least 4-10 words, points to at least one body part.

- Autism Screening: MCHAT score: _. Seems to interact with others well. Makes eye contact.

- Enjoys pretend play. Orients to name. Points and gestures socially. Using 2-word phrases.

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).

- MCHAT done today - No concerns.

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

- Follow up at 2 years of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- HepA #2, 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 years of age (ideally 2) 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, time outs, setting limits, routines.

- Emerging independence (offer choices)

- Growing vocabulary (importance of reading and talking)

- Limiting screen time

- Sleep: Nightmares, sleep hygiene

- Hazards of second hand smoke

290 views0 comments

Recent Posts

See All

The patient has been counseled on the procedure as well as risks, benefits, and alternatives. The procedure is considered irreversible and if they desire it to be reversed, it will require a much mo

Supportive care: Encourage fluids, activity as tolerated, honey for cough, salt water gargles, nasal saline. Tylenol or ibuprofen as needed for discomfort or fever > 102.5 Return if no improvement in

ASQ: Communication: Gross motor: Fine Motor: Problem Solving: Personal-Social: Interpretation / Concern / Plan: Dental assessment performed: No problem suspected, no referral needed Nutritional Assess