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 year old

SUBJECTIVE:

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

REVIEW OF SYSTEMS:

- Diet: No concerns.

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

- Sleeping: No concerns. Has regular bedtime routine.

- Dental: + brushes teeth. Sees the dentist regularly.

- Behavior: No concerns.

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

PM/SH:

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

DEVELOPMENT:

- Gross and fine motor: Hops/balances on one foot, can stack 8 blocks, brushes own teeth, dresses self (including buttons), uses scissors, walk up stairs with alternating feet, copies a cross.

- Cognitive: Knows first and last name, age, sex; draws person with at least 3 body parts; names at least 4 colors.

- Social/Emotional: Plays cooperatively, plays board/card games, plays make-believe.

- Communication: Strangers can understand speech, recognizes most letters. Speaks in 3-4 word sentences.

SOCIAL:

- No smokers in the home.

- No major social stressors at home.

- No safety concerns in the home.

- In preschool.

- 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.

LABS/STUDIES:

- Urine dip normal.

- Hearing screen normal.

ASSESSMENT/PLAN:

* Healthy 4 yo child

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

- CBC ordered. No indication for a lipid panel or DM screening.

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

- Follow up at 5 years of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Kinrix (DTaP #5, IPV #4), MMR #2, Varicella #2, Influenza

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

- Safety: Street/car safety, strangers, gun safety, helmets and safety equipment.

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

- Food: Limiting juice and junk/fast food.

- Discipline: Praising wanted behaviors, time outs, setting limits, routines, offering choices.

- Speech: Importance of reading, limiting screen time.

- Dental care and fluoride; dental visits

- Hazards of second hand smoke

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