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 year old

SUBJECTIVE:

2yo _ here for well child check. No parental concerns at this time.

REVIEW OF SYSTEMS:

- Diet: No concerns. Weaned from bottle.

- Voiding/stooling: No concerns. Working on toilet training.

- Sleeping: No concerns. Has regular bedtime routine.

- Dental: Weaned from the bottle. + brushes teeth with help. Has already been to the dentist.

- 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: Walks up/down steps, able to kick a ball, jumps in place, throws a ball overhand.

- Fine motor: Turns a page one at a time, removes clothes, stacks 5-6 blocks.

- Cognitive: Follows 2-step commands, scribbles, names items in pictures, uses spoon and cup well.

- Social/Emotional: Copies adults, plays pretend, plays well alongside other children.

- Communication: Able to put 2 words together, knows 20+ words.

- 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. BMI at _ percentile.

ASSESSMENT/PLAN:

* Healthy 2yo toddler

- CBC and lead level ordered.

- 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 2.5 years of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Influenza

- None

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

- Safety: Street/car safety, water safety, toxins, gun safety.

- Booster seat required by law until 8 yrs old or 4’9”

- Food: Picky eating, fortified 2% milk, limiting juice and junk/fast food.

- Development: Toilet training, limiting screen time.

- Discipline: Praising wanted behaviors, tantrum management, time outs, setting limits, routines, offering choices, don’t expect sharing.

- Speech: Normal speech dysfluency, importance of reading to child.

- Dental care and fluoride; dental visits

- Sleep: Nightmares, sleep hygiene

- Hazards of second hand smoke

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