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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

General Consent

[_] During the informed consent discussion regarding the procedure, or treatment, I explained the following to the patient/designee:

a. Nature of the procedure or treatment and who will perform the procedure or treatment.

b. Necessity for procedure and the possible benefits.

c. Risks and complications (most common and serious).

d. Alternative treatments and the risks, benefits and side effects of each (including no treatment).

e. Likelihood of the patient achieving his/her goals without this procedure and surgery treatment.

f. Problems that might occur during the recuperation.

g. Conflicts of interest, if any


[_] The procedure was emergent, the patient was unable to provide consent, and a designee was not immediately available.

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