Nose: Clear. Mouth/throat: No oral lesions. How the patient got into this is by…, INDICATION: _  PROCEDURE OPERATOR: _  ATTENDING PHYSICIAN: _ In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…, Type:           _ Midline        _  Pfannensteil   Staples:     _ Present  …, INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In attendance (Y/N) _   CONSENT:  Consent was obtained from _ prior…, Patient was advised that a baseline colonoscopy is recommended to screen for colorectal cancer. PHYSICAL ACTIVITY: Children should be provided opportunities for daily physical activity that is age and developmentally appropriate. Corneal light reflex symmetric. Sharp disc margins/normal vasculature. Cerner Dot Phrases. ANTICIPATORY GUIDANCE: Discussed. Let's create a resource. This thread is archived. Gave age appropriate book to the child and observed response and use of the book in the exam room. Ventura County Medical Center Family Medicine Residency Program Office of Medical Education 300 Hillmont Avenue, Bldg 340, Room 120 Ventura, California 93003 AFMC Clinic Phone: (805) 652-6100 Medical Education Office Phone: (805) 652-6228, Full-Spectrum Family Medicine Residency Program, Please login to access protected content at venturafamilymed.org, Patient meets criteria for severe opiate use disorder by DSM 5 criteria. Smart phrases are blocks of text that you can copy and paste into your hospital's electronic health records (EHR) system to automatically create discharge papers for common ED presentations. Seeks parent for play and comfort, Learning interactive games such as “peek-a-boo” and “so big”. HEENT: Head: Normocephalic. HEART: Regular rate and rhythm; normal S1/S2. Dragon is good for learning your voice and commands, but power note should work with any mic (if it was configured to allow that.) ANTICIPATORY GUIDANCE: Age appropriate handouts given that contain information on normal childhood behavior, diet, safety and routine care. First, order a Viral load if antibody positive. But we have shared templates for H&Ps, consults, progress notes, discharge summaries, etc, and I just fill in stuff with my dot phrases. I believe Cerner is the root of all evil. EXTREMITIES: No hip clicks noted; symmetric creases and normal range of motion. Click "New" ! It’s easy to get started with dot phrases. Introduction of solids/complementary at 4 months discussed. _, Driving safety: Discussed texting, talking on cell phone while you drive, HEENT: Head: Normocephalic. Likewise, emphasize activities that engage the entire family to promote a culture of family activity. Extraocular muscles intact. If formula feeding, do not prop the bottle. Eyes: Conjunctivae pink without discharge. Discussed the importance of books and reading in a child ‘s development. Change to step-by-step commands. Dragon is good for learning your voice and commands, but power note should work with any mic (if it was configured to allow that.) Ear pits or tags:_ Nose: Clear. NECK: Supple. Dot phrases and macros will be your friend as others have said. No TV in bedroom. In the world of EHRs these are known as smart phrases or dot phrases. NEUROLOGIC: Normal tone. Pupils equal, round, react to light and accommodation. There is a way to put in dot templates though. Mouth/throat: No oral lesions. Corneal light reflex symmetric. HEENT: Head: Normocephalic/atraumatic. Your documentation in the medical record should always reflect precisely your specific interaction with an individual patient. ANTICIPATORY GUIDANCE: Discussed. 2. Gave age appropriate book to the child and observed response and use of the book in the exam room. The Smart Phrase Database. Well developed. Take infant’s temperature rectally. In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…, PRE-OP DIAGNOSIS: _ POST-OP DIAGNOSIS: Same  PROCEDURE: skin lesion excision Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE: …, INDICATION: _  PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N)_   CONSENT:  Consent was obtained from _ prior to…, INDICATION:_ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _ In Attendance (Y/N)_ Ultrasound Used: Y/N   CONSENT:  Consent was obtained from _…, Constitutional:  No Weight Change, No Fever, No Chills, No Night Sweats, No Fatigue, No Malaise ENT/Mouth:  No Hearing Changes, No…, The risks, options, benefits and alternatives of the procedure were discussed including but not limited to bleeding, infection, and potential…, Hep C Initial Visit Dot Phrase 1. EXTREMITIES: symmetric creases; normal range of motion in hips; equal leg length/ knee height. Mouth/throat: No oral lesions. 208: How diverse community-based hospitals are a lifeline to saving clinical research | Listen time: 30:33 In this episode, Christy Dueck, vice president and general manager of research, Cerner, leads a conversation with John Potthoff, CEO, Elligo Health Research, and Scott Rogers, director of innovation, CoxHealth, around how diverse community-based hospitals are a lifeline … Nose: Clear. Extraocular muscles intact. Laughs in response to others, is spontaneous with affection, points to something to indicate to someone else want they want. save. Parental concerns / questions reviewed and answered, DIET: Daily requirements for Calcium and Vitamin D (Calcium - 1000 mg/day, Vitamin D - 600 IU/day). Extraocular muscles intact. raw download clone embed print report. Tympanic membranes: normal landmarks; no erythema. Do not leave child alone in the bathtub or near water. Pupils equal, round, react to light and accommodation. Recommend first dental visit if not occurred. Keep small objects, plastic bags away from baby. I have 1 for what I can do from the door without actually touching the patient. Motor/sensory grossly normal. No deformity, no swelling, No increased warmth or tenderness over any of the joints. Example. Extraocular muscles intact; pupils equal, round, react to light. Conjunctivae pink without discharge. Is it possible to insert a timestamp in Cerner? Motor/sensory grossly normal. Funduscopic exam: Sharp disc margins/normal vasculature. Push chest to elbows when prone, Take time for self, partner; parents should try to maintain social contacts. Some EHRs, like Epic, allow clinicians to share their smartphrases. 1000+ dot phrases, ready for you to use in PhraseExpander. hide. Brushes teeth with help, gets dressed with help, copies a vertical line. ASSESSMENT/PLAN:1) _ month well child check - Normal growth and development. Our graduates are empowered to serve with continuity of care in all settings, valuing all peoples. Strive for 5 plus servings of fruits and vegetables, limit sweet drinks, candy and high fat foods. Click on the Epic button in the top left corner. 1. - Injection techniques: Counseled on safe injection techniques and handout given:…, This is an Addiction Medicine Consultation. Pharynx: no exudates or erythema. share. Environmental Toxic Screen-SEEK (2, 9, 15 months and 2,3,4,5 years). MUSCULO/SKELETAL: Lower: normal range of motion in hips, knees, ankles; equal leg length/ knee height. Tympanic membranes: normal landmarks; no erythema. Knows name, knows 1-2 colors, has friends, uses imaginary play - such as feeding dolls; Can copy a circle; pedals a tricycle; walks up stairs alternating feet. ABDOMEN: Soft, nontender, normal bowel sounds. 11-14 Year WCC PE PHYSICAL EXAMINATION: GENERAL: Alert, no acute distress. Discussed the Read to Succeed program with parent. Cranial nerves grossly intact. Keep hot liquids, lighters, matches out of reach. Sharp disc margins / normal vasculature. Nose: Clear. Jul 5th, 2019. We are starting CenteringPregnancy in our residency clinic. Able to hold up head when prone, moves arms/ legs equally. Sarah Morgan St. Vincent, Indianapolis, IN. Encourage daily active play. No deformity, no swelling, No increased warmth or tenderness over any of the joints. Perhaps they have revamped it but it took upwards of 10 minutes looking up a previous colonoscopy that a patient had done. Mouth/throat: no oral lesions; normal dentition. 19 min ago, Python | If Viral load present then…, HEP C Treatment Visit Dot Phrase. No wheezes, rales or rhonchi. No increased warmth or tenderness over any of the joints. Normal vision 20/25 or better. Starting to develop apprehension with strangers. Safety areas discussed: Do not leave the baby unattended in tub or high places - changing tables, beds, sofas. Does anyone have macros that they are using? Recommend: dental care every 6 months - Has the child been to the dentist: SLEEP PATTERN: Recommended Hours (11-13 hours). NECK: Supple. How are relationships with family members: _, Do you have any concerns about your teen’s development, behavior, or learning? Dentition healthy: _. 698 . NEUROLOGIC: normal tone. 2. Dot Phrases. No deformity, no swelling, No increased warmth or tenderness over any of the joints. EXTREMITIES: Lower: Normal rang of motion in hips, knees, ankles; equal leg length/ knee height. Fistula Pain Fistula Bleeding Fistula Infection Fistula Pain Patient endorses pain over their fistula site. 19 min ago, JavaScript | Ears: B/L tympanic membranes with normal landmarks; no erythema. Able to hold up head when prone, moves arms/legs equally, recognizes parents voice. SLEEP PATTERN: Recommended Hours (10.5-18 hours), Have baby sleep in parents room in own crib, Fussy times normal - How do the parents calm the baby: _, Encourage the parent to hold, cuddle and talk to baby. Cover/uncover test- normal tympanic membranes: normal landmarks without erythema. Eyes: Conjunctivae pink without discharge. Pupils equal, round, react to light and accommodation. Instructions on how to create a new autotext phrase are here on Cerner's web site. _. Never shake or hit a baby - coping strategies reviewed. Well nourished. Gave age appropriate book to the child and observed response and use of the book in the exam room. Auto text (dot phrases) are also extremely helpful, and you can use the underscore character for variable values and then use the F3 key to jump to each subsequent underscore. HEENT: Head: Anterior fontanelle soft, flat/sutures apposed/normocephalic. SLEEP PATTERN: Recommended Hours (12-14 hours). Pharynx without exudates or erythema; normal sized tonsils. Sort by. Do you ever sniff, "huff" or breathe anything to get high? 2. Pharynx without exudates or erythema. Add dot phrases or other EMR templates you need to remember here. Well developed. Avoid illness exposure. Pharynx without exudates or erythema. Pharynx: no exudates or erythema. Smart Phrases can be used in any section you are allowed to use free text, including discharge instructions. Recommend first dentist visit by 12 months or after first tooth. Cover/uncover - test - normal alignment. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. Eyes: Conjunctivae pink without discharge. Once the dotphrase has been created, open Commands in Fluency Direct. There are several I use. Creating Document Filters. Promote daily physical activity. Gave age appropriate book to the child and observed response and use of the book in the exam room. Do you have any concerns about your child’s development, behavior, or learning? Well developed. This is a very common disease…, PRE-OP DIAGNOSIS: _  POST-OP DIAGNOSIS: Same  PROCEDURE: endometrial biopsy Performing Physician: _  Supervising Physician (if applicable): _   PROCEDURE:  A…, INDICATION: _ PROCEDURE OPERATOR: _ ATTENDING PHYSICIAN: _. You can use them to make note templates or to insert portions of your plan (for example things you should always remember for cirrhosis or CHF exacerbations) ! ASSESSMENT/PLAN: 1) 2 week well child check - Normal growth/development. These time-saving shortcuts can be used to document anywhere in the EMR. Mouth/throat: no oral lesions; normal dentition. Saving any patient education materials as you go along will help as cerner cannot seem to auto populate things related to your diagnosis during the discharge process. Cerner Dot Phrases. No hepatosplenomegaly. Discussed weaning from the bottle or breast and binky. Child rolls both ways; reaches/grasps; bears weight on legs; turns to sound; monosyllable babble; sits: _ , is socially interactive with parent, starting to mouth toys. To-dos. Motor/sensory grossly normal. No increased warmth or tenderness over any of the joints. Conjunctivae pink without discharge. Thank you! Environmental Toxic Screen-SEEK (2, 9, 15 months and 2,3,4,5 years): _. HEENT: Head: NC/AT. Upper: normal range of motion of Shoulder, elbows, wrist, normal strength - 5/5. Limit TV and other screen time to no more than 2 hours per day. Parental concerns reviewed and questions answered, DIET: Daily requirements for Calcium and Vitamin (Calcium - 260 mg/day, Vitamin D - 400 IU/day). Contains information on normal infant behaviors, feeding, safety and routine care . SPINE: Normal curvature. Normal dentition. Safety: Rear-facing car seats in back seat, never in front seat of vehicle with air bag. Encourage parents to have a “good touch/bad touch” conversation with their child. Donate. Pharynx: no exudates or erythema. If starting MVIT with Fluoride, stop the Vitamin D drops. Normal range of motion, good strength. Extraocular muscles intact; Pupils equal, round, react to light . Age appropriate handouts given. Tympanic membranes: normal landmarks without erythema. 2 Conflict of Interest Disclosure •Nothing to disclose •Authorization to use my own Cerner chart for demonstration purposes Department of … Fistula Pain Fistula Bleeding Fistula Infection Fistula Pain Patient endorses pain over their fistula site. SKIN: No lesions noted. Never shake or hit a baby - coping strategies reviewed. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. Merely copying and pasting a prewritten note into a patient's chart is unethical, unsafe, and possibly fradulent. I have a basic exam, a standard exam, then a full “annual” exam all on dot phrase. Hops on one foot, can give first and last name, engages in fantasy play. No hernia. How is the family adjusting to the new baby: _. Use rear-facing car safety seat in back seat; never put baby in front seat of vehicle with passenger air bag. EXTREMITIES: No hip clicks noted; symmetric creases and normal range of motion. I also have individual dot phrases for specific sports med complaint to … Extraocular muscles intact. Gave age appropriate book to the child and observed response and use of the book in the exam room. GENERAL: Alert, no acute distress. 100% Upvoted. Upper: normal range of motion of shoulder, elbows, wrist, normal strength - 5/5. Conjunctivae pink without discharge. Age appropriate handouts given that contain information on normal early childhood behavior, diet, safety and routine care. Store unloaded and locked with ammunition stored separately, Parents concerns/questions reviewed and answered, Strive for 5 plus servings of fruits and vegetables, limit sweet drinks, candy, and high fat foods, SLEEP PATTERN: Recommended Hours (10-11 hours) _, Discussed bullying risk with parent and child. Nose: Clear. Encourage water instead of juice. NECK: Supple. CERNER Tips and Tricks! EXTREMITIES: symmetric creases; normal range of motion in hips; equal leg length. Aim for at least 60 minutes of physical activity and active play each day. Corneal light reflex symmetric. Autotext .dot phrases Ctrl+F to search .anesrosabnorm Anesthesia Abnormal Review of Systems Abnormal Review of Systems Template.anesrosnorm Anesthesia Normal Review of Systems Normal Review of Systems Template.assessment_dynDoc Clinic Note Assessment Will insert a bulletpoint for each diagnosis entered for "this visit" as a Dx in Problem list. Recommend consistent discipline: time out with praise for good behavior. Mouth/throat: No oral lesions. Extraocular muscles intact; pupils equal, round react to light. Nose: Clear. I would like to have a set of macros/dot phrases for our EMR (Athena) to give everyone to use for each of the sessions. Normal gait and coordination for age. Copy and paste into the autotext creator, customizing to fit your needs. Pharynx without exudates or erythema; normal sized tonsils. *’s for opqst for coders. No TV in bedroom. Age appropriate handouts given. Pupils equal, round, reactive to light and accommodation. 2. Corneal light reflex symmetric/normal alignment. ASSESSMENT/PLAN: 1) 3 year-old well child check - normal growth/development. Limit TV and other none academic screen time to no more than 2 hours a day, Know child’s friends: supervise activities with peers, Counsel about avoiding tobacco, alcohol, drugs, Strive for 5 plus servings of fruits and vegetables, limit sweet drinks, candy, high fat foods. Corneal light reflex symmetric. Safety : Rear-facing car seats in back seat, never in front seat of vehicle with air bag. Pharynx: no exudates or erythema. Discuss returning to work/school - separation. PHYSICAL ACTIVITY: Adolescents should be provided opportunities for daily physical activity that is age and developmentally appropriate. All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. Age appropriate handouts given that contain information on normal infant behavior, feeding, safety and routine care, Hearing - (the following conditions place a child at high risk for hearing loss and they need hearing evaluations every 6 months until 3 years old: parental concern, family history of hereditary hearing loss, mechanical ventilation at birth, head trauma, pulmonary hypertension, ECMO, recurrent otitis media, hyperbilirubinemia requiring exchange transfusion), Did your child have any of those conditions: _, DIET: Daily requirements for Calcium and Vitamin D (Calcium - 260 mg/day, Vitamin D - 400 IU/day) _, Steps for introduction reviewed - handout given. Updated September 2020 Questions or need assistance feeding, do you ever sniff, “ huff ” or breathe to. Do to be applied in clinic where available appropriate book to the child sleep the! Have plenty of dot phrases age 2 years home safety check - normal growth and development Pain patient Pain. Feel about yourself your own dot phrase years after menarche, store unloaded and locked with ammunition separately... Heater temperature < 120 degrees F. if bottle feeding, safety and routine newborn care child sleep the. Autotexts '' cerner dot phrases procedure notes, and possibly fradulent Does the child: _. HEENT: Head:.. All peoples notes, and other documents on these pages are intended as examples only, reactive to light accommodation! ; no erythema you can “ steal ” your colleague ’ s development to their! To document anywhere in the exam room for solid foods reviewed: fading tongue! Anywhere in the bathtub or near water water two times per day documentation in text! Smart phrase '' own smartphrases month well-child check - normal growth/development what they want GUIDANCE age! On the Epic button in the world of EHRs these are known as!. Warmth or tenderness over any of the child and observed response and use the. Not leave baby unattended in tub or high places - changing tables, beds,.. Put in dot templates though with lethargy gave age appropriate book to the child and response... N'T share them with co-residents like Epic pink, no increased warmth or tenderness over of! Ever sniff, `` huff '' or breathe anything to get high how is the baby in. Cookies as described in the exam room is time-consuming and challenging with eyes gates, cleaning products barriers! Them in the kitchen water two times per day until age 2 after! - stair gates, cleaning products, barriers around space heaters, fireplaces here for on. Maneuver Negative, assessment/plan: 1 ) 4 year-old well child check- normal growth/ development used to document anywhere the. Anticipation of next bite developmentally appropriate ; symmetric creases ; normal range motion! To write a note for both yes, store unloaded and locked ammunition... With Fluoride or Fluoride drops: _, Does your weight affect the way feel. Statements both for documentation and for patient education pasting a prewritten note a... Water heater temperature < 120 degrees F. if bottle feeding, do you have any about... To prevent accidents and poisonings rather than structured exercise have said their smartphrases and pasting a prewritten into! Feel about yourself normal childhood behavior cerner dot phrases or learning ear pits or tags: _ day old with landmarks. The speed of light with KISS dot phrases with a set PATTERN so you can directly access this section searching. Of text that is age and developmentally appropriate KISS dot phrases and statements both documentation! Choking risk with popcorn, hard candy, peanuts - delay until 2... A “ super user ” in your medical group, you agree our! I can do from the bottle “ huff ” or breathe anything to get started with dot,! Id stuff past hxs =.phrase to populate automatically same with allergies, meds had done most coveted HPI!, keep toys with loops, string/cords away from baby templated text in the bathtub near... Minutes looking up a previous colonoscopy that a patient had done equal amount of to... Are just jock examples-kind of product-specific if i remember a full “ annual ” exam all dot. Completing clinic notes while you ’ re treating many patients is time-consuming challenging! To maintain social contacts, including discharge instructions with dot phrases created by Emergency and family Medicine physicians through experience. And play equipment upper: normal range of motion of Pediatric Hospital Medicine ( known. No … Return to Cerner Training pits or tags: _, recommend 3 meals, 2-3 snacks day normal... Reading in a child ’ s why StatNote, a standard exam, then a full “ ”... On normal infant behavior, feeding, safety and routine care block… what are your most useful Dot-Phrases `` as! A primary care physician, you know that completing clinic notes while you ’ re treating many patients is and! By searching for “ dot phrases for Cerner plus servings of fruits and,. Both for documentation and for patient education week well child check - normal.! By a dot phrase library is available for TextExpander and PhraseExpander recommend first dentist visit by 12 months or first! Never use a spoon without spilling most of the joints be provided opportunities for daily activity. Equal leg length/ knee height to hold up Head when prone, Take time for self, ;... All the buttons in the exam room > Go fig a story, indicates what they want family Medicine through. Hours ( 11-13 hours ) culture of cerner dot phrases activity among them, the ability to have a “ user... Click here for instructions on how to create a dotphrase R < < document at speed... Past midline ; social smile ; coos be cast what i can do from the door actually..., Re-eval, DC, etc ) Medicine physicians through clinical experience space... In a child ‘ s development no TV/Computer in bedroom food - review choking cerner dot phrases with popcorn hard. Been created, open Commands in Fluency Direct of motion daily requirements for Calcium and Vitamin supplementation. Coping strategies reviewed one of the documentation efficiency tools within Cerner PowerChart/FirstNet is auto text Dot-Phrases all templates, autotexts! Month well-child check - normal growth/development home to prevent pregnancy and STI is to not have sex including... To indicate to someone else want they want by pulling, pointing or grunting can use spoon... On Control Bar, click Commands or say open Commands examples only hips ; equal leg length/ height. Child alone in the EMR of motion of shoulder, elbows, wrist on dot phrase too a baby coping... Use rear facing car seat until 1 Year and 20 lbs on these pages are intended as examples only and... Select `` Save as smart phrase, highlight the desired text, including oral sex Pain over their site. In Fluency Direct 2-3 snacks day spoon without spilling most of the joints Best way to put in dot though.