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 8-11 year old

8-11 YEARS SUBJECTIVE: _ here for well child check. No parental or patient concerns at this time.

Here with parent: _ REVIEW OF SYSTEMS: - Diet: No concerns. - Fast food, soda, juice intake: _ - Calcium intake: _ - Dental: + brushes teeth. Sees the dentist regularly. - Sleep concerns (duration, snoring, bedtime): None. - Elimination concerns (including menses in females): _ PM/SH: Normal pregnancy and delivery. No surgeries, hospitalizations, or serious illnesses to date. DEVELOPMENT: - In _ grade. School is going well. No parental or teacher concerns about behavior. - Friends/hobbies (i.e. after school activities): _ - Physical activity (and safety): _ - Screen time: _ SOCIAL: - Noteworthy social stressors: _ - No smokers in the home. - No TB or lead risk factors. IMMUNIZATIONS: - Up to date. OBJECTIVE: - VITALS: _ - WEIGHT: BMI _ - 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 genitalia, Tanner stage _ - SKIN: WWP. No skin rashes or abnormal lesions. - MSK: No deformities or signs of scoliosis. Normal gait. No clubbing, cyanosis, or edema. - NEURO: Normal muscle strength and tone. No focal deficits. LABS/STUDIES: - Urine dip normal. - Hearing screen normal. - Snellen testing: _ ASSESSMENT/PLAN: * Healthy _ yo child - CBC ordered. No indication for DM screening. - Check lipid panel between 9-11 yo, repeat 18-21 yo. - Screen for depression _ >12 yo. - Follow in one year, or sooner PRN. - ER/return precautions discussed. * Vaccines today: - Influenza, HPV (0, 1-2, and 6 months, starting at age 9), Tdap (11-12), Meningococcal (11-12) * Anticipatory guidance (discussed or covered in a handout given to the family) - Puberty - Peer pressure, bullying, communication with teachers, violence prevention - Seat belts, helmets and safety gear, sunscreen - Internet safety, limiting screen time - Appropriate discipline for age - Healthy food, exercise, good dental hygiene - Eliminating guns from the home, or locking bullets separately - Hazards of second hand smoke

3,537 views0 comments

Recent Posts

See All

The patient has been counseled on the procedure as well as risks, benefits, and alternatives. The procedure is considered irreversible and if they desire it to be reversed, it will require a much mo

Supportive care: Encourage fluids, activity as tolerated, honey for cough, salt water gargles, nasal saline. Tylenol or ibuprofen as needed for discomfort or fever > 102.5 Return if no improvement in

ASQ: Communication: Gross motor: Fine Motor: Problem Solving: Personal-Social: Interpretation / Concern / Plan: Dental assessment performed: No problem suspected, no referral needed Nutritional Assess