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: 6-8 week

6-8 WEEKS

SUBJECTIVE:

_-week old infant here for a routine well child check and vaccines. No parental concerns/ questions today.

ROS:

- Eating well: _

- Stooling/voiding normally.

- Behaving normally.

- No concerns about sleep at this time.

PM/SH:

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

DEVELOPMENT:

- Gross motor: Able to hold head somewhat steady when pulled to a sitting position. Able to push body up when prone.

- Fine motor: Moving all extremities symmetrically. Can hold an object briefly.

- Cognitive: Indicates boredom when minimal stimulation. Eyes track well, and can fix on objects.

- Social/Emotional: Smiles, looks at parents, able to comfort self.

- Communication: Coos, vocalizes. Has different cries for different needs.

SOCIAL HX:

No smokers in the home. Stable, tranquil family. No major social stressors at home. Mother is doing well. Daytime care is _

FAMILY HX:

No h/o SIDS, atopic disease

OBJECTIVE:

- VITALS: _

- WEIGHTS: BW _. Today's weight _.

- 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 jaundice, new skin rashes, or abnormal lesions.

- MSK: Normal extremities & spine. No hip clicks or clunks.

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

NEWBORN SCREEN:

- Results all negative.

ASSESSMENT/PLAN:

* Healthy newborn infant, doing well.

- Routine care.

- F/u at 4 months of age, or sooner PRN.

* Vaccines today:

- Pediarix #1 (DTaP, IPV, HepB #2), PCV #1, Rota #1, Hib #1

- Pentacel #1 (DTaP, IPV, Hib), PCV #1, Rota #1, HepB #2

- Comvax (Hib #1, HepB #2), PCV #1, Rota #1, DTaP #1, IPV #1

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

- Common immunization SE’s

- Nutrition and feeding; growth spurts

- Normal sleep patterns. Infant should always sleep on back to prevent SIDS

- Tummy time

- Range of normal bowel habits

- 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 (ideally 2) and 20 pounds

- Working smoke alarms and carbon dioxide monitors in home

- No smokers in the home

- Hot water heater to less than 120 degrees

- Fall prevention

- Normal crying versus colic, and what to expect

- Warning signs for postpartum depression versus baby blues

- Sibling adjustment

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

- Formula mixing

- 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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