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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

Exam: Psych

Arousal: Alert

Attentiveness: fully attentive

Appearance: well-dressed and well-groomed

Attitude: cooperative, not guarded

Activity: calm, not restless, no abnormal movements, good eye contact

Orientation: Fully oriented

Mood: euthymic, not dysphoric, euphoric, apathetic, anxious or angry

Affect: normal range, not restricted, flat, or labile

Verbal: normal expressive and receptive language function

Thought process: organized, goal-directed. Pt did not require redirection.

Thought content: no delusions, no suicidal/homicidal ideation

Perceptions: not responding to internal stimuli

Insight/Judgment: good insight, judgment appears to be good

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