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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.

venturafamilymed

Review of Systems, Full

Constitutional: No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise ENT/Mouth: No Hearing Changes, No Ear Pain, No Nasal Congestion, No Sinus Pain, No Hoarseness, No sore throat, No Rhinorrhea, No Swallowing Difficulty Eyes: No Eye Pain, No Swelling, No Redness, No Foreign Body, No Discharge, No Vision Changes Cardiovascular: No Chest Pain, No SOB, No PND, No Dyspnea on Exertion, No Orthopnea, No Claudication, No Edema, No Palpitations Respiratory: No Cough, No Sputum, No Wheezing, No Smoke Exposure, No Dyspnea Gastrointestinal: No Nausea, No Vomiting, No Diarrhea, No Constipation, No Pain, No Heartburn, No Anorexia, No Dysphagia, No Hematochezia, No Melena, No Flatulence, No Jaundice Genitourinary: No Dysmenorrhea, No DUB, No Dyspareunia, No Dysuria, No Urinary Frequency, No Hematuria, No Urinary Incontinence, No Urgency, No Flank Pain, No Urinary Flow Changes, No Hesitancy Musculoskeletal: No Arthralgias, No Myalgias, No Joint Swelling, No Joint Stiffness, No Back Pain, No Neck Pain, No Injury History Skin: No Skin Lesions, No Pruritis, No Hair Changes, No Breast/Skin Changes, No Nipple Discharge Neuro: No Weakness, No Numbness, No Paresthesias, No Loss of Consciousness, No Syncope, No Dizziness, No Headache, No Coordination Changes, No Recent Falls Psych: No Anxiety/Panic, No Depression, No Insomnia, No Personality Changes, No Delusions, No Rumination, No SI/HI/AH/VH, No Social Issues, No Memory Changes, No Violence/Abuse Hx., No Eating Concerns Heme/Lymph: No Bruising, No Bleeding, No Transfusions History, No Lymphadenopathy Endocrine: No Polyuria, No Polydipsia, No Temperature Intolerance

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