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 month old

6 MONTHS

SUBJECTIVE:

6 month old _ here for well child check. No parental concerns at this time.

REVIEW OF SYSTEMS:

- Diet: No concerns. Starting to try solids.

- Voiding/stooling: No concerns.

- Sleeping: Has a regular bedtime routine, and sleeps through the night without feeding.

- Behavior: No concerns.

PM/SH:

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

DEVELOPMENT:

- Gross and fine motor: Head flexed forward when pulled to a sitting position. Is able to sit up, rolls over both ways. Reaches and grabs; raking grasps.

- Cognitive: Responds to affection. Turns towards sounds.

- Social/Emotional/Communication: Smiles, laughs, likes to talk and play.

SOCIAL:

- No smokers in the home.

- No concerns regarding postpartum depression.

- No major social stressors at home.

- No safety concerns in the home.

- Daytime child care is with _

- No TB or lead risk factors.

IMMUNIZATIONS:

- Up to date.

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 nicely in all parameters.

ASSESSMENT/PLAN:

* Healthy 6-month old infant

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

- Follow up at 9 months of age, or sooner PRN.

- ER/return precautions discussed.

* Vaccines today:

- Pediarix #3 (DTaP, IPV, HepB #4), PCV #3, Rota #3, Hib #3, Influenza

- Pentacel #3 (DTaP, IPV, Hib), PCV #3, Rota #3, HepB #4, Influenza

- PCV #3, Rota #3, DTaP #3, IPV #3, Influenza (Hib, HepB to be given at 12-month visit)

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

- Common immunization SE’s

- Avoiding use of walkers and door swings/jumpers.

- Child proofing the home: Gates for stairs, burn prevention, kitchen safety, water safety

- Poison Control number (800-222-1222)

- Car seat facing backward until 2 years of age and 20 pounds

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

- How and when to introduce solids: Iron-fortified foods, delaying sweet foods and fruits, no honey/corn syrup/cow’s milk until one year old, finger foods

- Choking hazards

- No juice from bottle; no bottle in bed; early use of sippy cup

- Speech development (importance of reading and talking)

- Sleep: Separation anxiety, night awakening, sleep training, lower crib mattress, side rales up

- Warning signs for postpartum depression versus baby blues

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