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: 9 month old

9 MONTHS

SUBJECTIVE:

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

REVIEW OF SYSTEMS:

- Diet: No concerns.

- 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 motor: Sits well on own, crawls, cruises, pulls self to stand (with help)

- Fine motor: Uses pincer grasp, takes finger foods.

- Cognitive: +object permanence, likes to look at books.

- Social/Emotional: Laughs, likes to play games (e.g. “peek-a-boo”), early signs of stranger anxiety, seeks parents for comfort.

- Communication: Understands a few words, babbles, imitates sounds, says nonspecific syllables (“mama,” “dada”), points out objects.

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. Anterior fontanelle _

- 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 9-month old infant

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

- Follow up at 12 months 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)

- 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

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

- Food: Iron-fortified foods, no honey/corn syrup/cow’s milk until one year old, finger foods, no/minimal juice

- Choking hazards

- No juice from bottle; no bottle in bed; introducing a sippy cup

- Speech development (importance of reading and talking)

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

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