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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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  • venturafamilymed
    • Sep 8, 2021
    • 1 min read

Wound Check Visit Note

Subjective:

The patient presents today for a wound check. They deny fevers or malaise. The wound appears improved to the patient. The redness and drainage from the wound is decreasing. They have been able to manage dressing changes without difficulty at home.

Objective:

.vitals

Gen: nad

Wound – The drainage is serosanguinous as expected, no evidence of extension of erythema, the dressing was changed, the patient tolerated well

Assessment/Plan:

The wound is healing as expected. Dressing change performed today in clinic.

Follow-Up:

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