top of page

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.

Search
  • venturafamilymed
    • Sep 8, 2021
    • 1 min read

Excision of Benign Skin Lesion Procedure Note

PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same PROCEDURE: skin lesion excision Performing Physician: _ Supervising Physician (if applicable): _ PROCEDURE: _ Shave Biopsy _ Scissors _ Cryotherapy _ Punch (Size _) The area surrounding the skin lesion was prepared and draped in the usual sterile manner. The lesion was removed in the usual manner by the biopsy method noted above. Hemostasis was assured. Closure: _ Monsel’s for hemostasis _ suture _ _ None Followup: The patient tolerated the procedure well without complications. Standard post-procedure care is explained and return precautions are given.

16,892 views0 comments

Recent Posts

See All

Initial Medicare Annual Wellness Visit Checklist

HPI/Family /Social History Perform patient reported Health Risk Assessment Staying Healthy Assessment – Senior version Medical and Family History – By history – often in Cerner Current Providers List

Central Line Procedure Note

Central Line Procedure Note Indication: [_] Hypotension/Sepsis/Need for Pressors [_] Vascular Access [_] Dialysis Access [_] Suspected Central Line Infection [_] Line Malfunction [_] Other: _ Central

Disability Template

Date first seen for this problem: _ Date completing form: _ Treatment Intervals: [_] Daily [_] Weekly [_] Monthly [_] as needed. Date first incapable of work: _ Anticipated Release date to return to w

bottom of page