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.

 
  • venturafamilymed

Well Child Check: 5 year old

5 YEARS

SUBJECTIVE:

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

REVIEW OF SYSTEMS:

- Diet: No concerns.

- Fast food, soda, juice intake: _

- Calcium intake: _

- 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 and skips, holds crayon or pencil well, rides a bike, able to tie a knot; copies squares and triangles.

- Cognitive: Draws a person with head, body, and limbs (6+ body parts); knows at least 4 colors; counts to 5 or 10; can explain the use of a ball or shoe.

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

- Communication: Can speak in full sentences and tell a story, recognizes most letters, prints some letters and numbers.

SOCIAL:

- In kindergarten

- After-school activities:

- No smokers in the home.

- No major social stressors at home.

- No safety concerns in the home.

- 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 and nares normal. MMM. Normal gums, mucosa, palate, OP. 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: No deformities. Normal gait. No clubbing, cyanosis, or edema.

- 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.

- Snellen testing: _

ASSESSMENT/PLAN:

* Healthy 5 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.

- Follow up at 6 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, strangers, gun safety, helmets and safety equipment.

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

- Food and exercise: Limiting juice and junk/fast food, exercise.

- Memorize name, address, and phone number.

- Speech: Importance of reading, limiting screen time.

- Dental care and fluoride; dental visits

- Hazards of second hand smoke

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