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: 4 month old

4 MONTHS

SUBJECTIVE:

4-month old infant here for a well child check. No parental concerns/questions today.

ROS:

- Eating well: _

- Hasn’t tried solids yet.

- No concerns about stooling or voiding.

- Bedtime routine: _

PM/SH:

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

DEVELOPMENT:

- Gross motor: Good head control, including when prone. Good head control when pulled to a sitting position.

- Fine motor: Able to roll from front to back. Reaches for objects, and holds them briefly.

- Cognitive: Responds to affection. Indicates pleasure and displeasure.

- Social/Emotional: Laughs, squeals. Can self-calm.

- Communication: Babbles, smiles.

SOCIAL:

- No smokers in the home.

- No postpartum depression in mother.

- No major social stressors at home.

- Daytime child care is with _

- No TB risk factors.

OBJECTIVE:

- VITALS: _

- GEN: Normal general appearance. NAD.

- HEAD: NCAT. AFOSF.

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

- ENMT: TMs, nares, and OP normal. MMM. No abnormal oral lesions.

- NECK: Supple, with no masses.

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

- 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. No hip clicks or clunks.

- NEURO: MAE symmetrically. Normal muscle strength and tone.

GROWTH CHART: Following growth curve well in all parameters.

ASSESSMENT/PLAN:

* Healthy 4-month old infant

- Follow up at 6 months of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Pediarix #2 (DTaP, IPV, HepB #3), PCV #2, Rota #2, Hib #2

- Pentacel #2 (DTaP, IPV, Hib), PCV #2, Rota #2, HepB #3

- Comvax (Hib #2, HepB #3), PCV #2, Rota #2, DTaP #2, IPV #2

* Premature (< 37 weeks) or < 5.5 lbs

- Consider hemoglobin

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

- Common immunization SE’s

- How and when to introduce solids

- Normal sleep patterns (decreased nighttime feeds, more regular sleep patterns)

- Infant should always sleep on back to prevent SIDS (first 6 months, at least)

- Teething (first tooth at 3-12 months, average 7 months)

- Tummy time; prevention of plagiocephaly

- Range of normal bowel habits

- Warning signs for postpartum depression versus baby blues

- 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

- Hot water heater to less than 120 degrees

- Fall prevention

- Normal crying versus colic, and what to expect

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

- 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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