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 year old

SUBJECTIVE:

6 year old _ here for well child check. No parental or patient concerns at this time.

REVIEW OF SYSTEMS:

- Diet: No concerns.

- Fast food, soda, juice intake: _

- Calcium intake: _

- Voiding/stooling: No concerns.

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

- Behavior: No concerns.

PM/SH:

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

DEVELOPMENT:

- In _ grade. School is going well.

- Has friends.

- After-school activities: _

- Physical activity (and safety): _

- Screen time: _

- Does chores when asked.

- Knows address and home phone number.

- Can name 4-5 things to eat in 20 seconds.

- Prints letters without problems.

- Dresses self without supervision.

SOCIAL:

- Noteworthy social stressors: _

- No smokers 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.

- 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 6 yo child

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

- Follow up at 7 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 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.

- School: Communicate with teachers, discuss peer pressure and bullying, internet safety.

- Speech: Importance of reading, limiting screen time.

- Dental care and fluoride; dental visits

- Hazards of second hand smoke

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