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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 3, 2021
    • 1 min read

Buprenorphine Maintenance Visit

S: Pt doing well on _ No sx of w/d. Cravings stable.

O:

Gen: NAD

COWS=0

A/P:

Opiate addiction:

Doing well on _ . Rx written: _.

F/u on _

PDMP cures run and _

UDS sent

Pt informed that they NEED to be involved in some sort of substance abuse counselling program. Pt states that they will actively be involved.

Gold Coast NA: 888-817-7425 http://www.gcana.org

Ventura County Behavioral Health Alcohol and Drug Program (ADP): 805-981-9200

Here to Help Program: https://www.suboxone.com/treatment-plan/patient-support


15 minutes spent in interviewing and counselling and discussing the plan and coordinating care.

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