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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: 3 year old


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


- Diet: No concerns.

- Voiding/stooling: No concerns. + toilet trained (during the day, at least).

- Sleeping: No concerns. Has regular bedtime routine.

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

- Behavior: No concerns.

- Activity: Screen/TV time is limited to < 2 hrs/day, gets time outside every day.


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


- Gross and fine motor: Can stack 6-8 blocks, stand on one foot, pedal a tricycle, throw a ball overhand, walk up stairs with alternating feet, copy a circle, draw a person with two body parts, dress self (may need some help).

- Cognitive: Knows name, age, sex. Counts to 3 or more.

- Social/Emotional: Joins other children in play. Asks questions. Able to name friends.

- Communication: Others can understand at least 3/4 of what is said. Speaks in 3-4 word sentences. MCHAT in chart.


- 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.


- Up to date.



- GEN: Normal general appearance. NAD.


- 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.


* Healthy 3yo child

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

- CBC ordered.

- MCHAT was done at 18 and 24 months of age.

- Follow up at 4 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 (Poison Control number: 800-222-1222), gun safety, helmets and safety equipment.

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

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

- Discipline: Praising wanted behaviors, time outs, setting limits, routines, offering choices, +expect sharing, limiting screen time.

- Speech: Importance of reading, temporary stuttering

- Dental care and fluoride; dental visits

- Sleep: Nightmares, sleep hygiene

- Hazards of second hand smoke

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