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: 2 week old

SUBJECTIVE:

2-week old infant born to a _ year old G_ at _. No parental concerns/questions today.

ROS:

- Eating well: _

- No concerns about stooling or voiding.

PM/SH:

Normal pregnancy and delivery.

DEVELOPMENT:

- Gross motor: Lifts head when on tummy.

- Fine motor: Moving all limbs equally.

- Cognitive: Starting to smile. Eyes are tracking objects/bright lights.

- Social/Emotional: + consolable. Appears to regard faces of others (at about 12 inches).

- Communication: Coos.

SOCIAL HX:

No smokers in the home. Stable, tranquil family. No major social stressors at home. Mother is doing well.

FAMILY HX:

No h/o SIDS, atopic disease

OBJECTIVE:

- VITALS: _

- WEIGHTS: BW _. Today's weight _.

- GEN: Normal general appearance. NAD.

- HEAD: NCAT. No cephalohematoma. AFOSF.

- EENT: Red reflex present bilaterally. Normal ext ears, nose, lips.

- MOUTH: MMM. Normal gums, mucosa, palate, OP.

- NECK: Supple.

- CV: RRR, no m/r/g. Normal femoral pulses.

- LUNGS: CTAB, no w/r/c.

- ABD: Soft, NT/ND, NBS, no masses or organomegaly. Normal umbilicus.

- GU: Normal _male genitalia. Testes descended bilaterally.

- SKIN: WWP. No jaundice, new skin rashes, or abnormal lesions. No sacral dimple.

- MSK: Normal extremities & spine. No hip clicks or clunks. No clavicular fracture.

- NEURO: MAE symmetrically. Normal moro & suck reflexes. Normal muscle tone.

NEWBORN SCREEN:

- Results all negative.

ASSESSMENT/PLAN:

* Healthy 2-week old infant, doing well.

- F/u at 6-8 weeks of age, or sooner PRN.

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

- Normal newborn feeding and sleep patterns

- Infant should always sleep on back to prevent SIDS

- Tummy time

- Range of normal bowel habits

- No smoking in home: risk for SIDS and asthma

- Safest to sleep in crib or bassinet

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

- Working smoke alarms and carbon dioxide monitors in home

- No smokers in the home

- Hot water heater to less than 120 degrees

- Fall prevention

- Normal crying versus colic, and what to expect

- Warning signs for postpartum depression versus baby blues

- Sibling envy

- No honey, corn syrup, cows milk until 1 year

- Formula mixing

- Poly-Vi-Sol supplement with iron if mostly breast feeding (< 32 oz/day of formula)

- How and when to contact us

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