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.

venturafamilymed

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.

541 views0 comments

Recent Posts

See All

Disability Template

Date first seen for this problem: _ Date completing form: _ Treatment Intervals: [_] Daily [_] Weekly [_] Monthly [_] as needed. Date...

Vasectomy Consent

The patient has been counseled on the procedure as well as risks, benefits, and alternatives. The procedure is considered irreversible...

bottom of page