cerner dot phrases

Tympanic membranes: normal landmarks; no erythema. best. Thank you! Please read in detail and delete what is not relevant. This is an ill-appearing *** who presents with lethargy. Keep track of to-dos here. Normal gait and coordination. ASSESSMENT/PLAN: 1) 2 week well child check - Normal growth/development. Put baby on the back to sleep. No lymphadenopathy. 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. Emphasis should be place on play rather than structured exercise. Eyes: Conjunctivae pink without discharge. Limit TV and other screen time to no more than 2 hours per day. No deformity, no swelling, No increased warmth or tenderness over any of the joints. ASSESSMENT/PLAN: 1) year-old well child check - normal growth/ development, Be physically active 60 minutes a day; be active as a family. Pharynx: no exudates or erythema. Discussed the importance of books and reading in a child’s development. >> Go fig. No lymphadenopathy. 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. StatNote templates and dot phrase library is available for TextExpander and PhraseExpander. Among them, the ability to have preformatted phrases and statements both for documentation and for patient education. Corneal light reflex symmetric. Ortolani/Barlow Maneuver Negative, ASSESSMENT/PLAN: 1) 1 month well child check - Normal growth/development. SKIN: No lesions noted. Ortolani/Barlow Maneuver negative. Tympanic membranes: normal landmarks; no erythema. This patient’s fistula did not display overt characteristics of Bleeding, Hematoma, Infection, Aneurysm, Vascular Insufficiency or other emergent problem. Click "New" ! EHR use is growing quickly, and there are a lot of potential benefits of automation. Age appropriate handouts given that contain information on normal toddler behavior, feeding, safety and routine care. I can't share them with co-residents like Epic. Auto Text Dot-Phrases All templates, "autotexts", procedure notes, and other documents on these pages are intended as examples only. Courtney MI - Michigan Centering Consortium. Mouth/throat: no oral lesions; normal dentition. Discussed age appropriate behavior when parent reads to the child and modeling behaviors the parent can use to enhance the child’s verbal skills and love of reading . 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. Well developed. Pupils equal, round, reactive to light and accommodation. Age appropriate handouts given. ASSESSMENT/PLAN: 1) 3 year-old well child check - normal growth/development. NEUROLOGIC: Normal tone. Ear pits or tags:_ Nose: Clear. Do you have any concerns about your child’s development, behavior, or learning? No discharge. Pharynx without exudates or erythema; normal sized tonsils. Upper: normal range of motion of shoulder, elbows, wrist, normal strength - 5/5. Sharp disc margins/normal vasculature. Mouth/throat: no oral lesions; normal dentition. No hepatosplenomegaly. Environmental Toxic Screen-SEEK (2, 9, 15 months and 2,3,4,5 years). Normal dentition. Insert “type text” with desired text, then pause of ~650ms if using dot phrases, and finally a key stroke with “enter” ASSESSMENT/PLAN: 1) 6 month well child check - normal growth /development. Mouth/throat: no oral lesions; normal dentition. Pharynx without exudates or erythema; normal sized tonsils. ANTICIPATORY GUIDANCE: Age appropriate handouts given that contain information on normal early childhood behavior, feeding, safety and routine care. Creating Document Filters. Discussed the Reach 2 Succeed program with parent. 1. (High risk factors for dental health issues - early referral to dental home: Children with special health care needs, mothers with high caries rate, demonstrable caries, chalky plaques, staining, sleeping with bottle, breastfeeding through the night). Give your AutoText a name – these are customarily named as “dot-phrases” because you put a “.” in front of whatever you choose to name the phrase To use the phrase in a note, type in “.” and review the list of options. _, Recommend a varied diet including adequate fruits and vegetables, Dairy/other source of calcium intake per day: _. EXTREMITIES: No hip clicks noted; symmetric creases and normal range of motion. Click "New" ! Eyes: B/L RR. Eyes: Bilateral RR. Normal vision - 20/40 or better. If yes, store unloaded and locked with ammunition locked separately. Has been using this for _. Tympanic membranes: normal landmarks without erythema. Pharynx: no exudates or erythema. Smart Phrases. No masses. In the world of EHRs these are known as smart phrases or dot phrases. Listens to a story, indicates what they want by pulling, pointing or grunting. Use rear facing car seat until 1 year and 20 lbs. Do not leave child alone in the bathtub or near water. As a primary care physician, you know that completing clinic notes while you’re treating many patients is time-consuming and challenging. This thread is archived. << STEP 3: Update the fields as necessary. Nose: Clear. Pupils equal, round, react to light and accommodation. Pharynx without exudates or erythema; normal sized tonsils. No deformity, no swelling, No increased warmth or tenderness over any of the joints. Funduscopic exam: Sharp disc margins/normal vasculature. Discussed the importance of books and reading in a child ‘s development. Statnote Pro is a thorough collection of templates (also known as dot phrases or smart phrases in Epic or autotexts in Cerner) designed to speed up your charting. Let's create a resource. Our graduates are empowered to serve with continuity of care in all settings, valuing all peoples. Document at the speed of light with KISS dot phrases @ statnote.com. Eyes: Conjunctivae pink without discharge. Eyes: Conjunctivae pink without discharge. Be physically active 60 minutes a day. best. Keep baby in high chair / playpen in the kitchen. Return To Cerner Training. SPINE: Normal curvature. ANTICIPATORY GUIDANCE: Discussed. Pharynx without exudates or erythema. ANTICIPATORY GUIDANCE: Discussed. ABDOMEN: Soft, nontender, normal bowel sounds. Cranial nerves grossly intact. Normal gait and coordination for age. 510 likes. NECK: Supple. Stool pattern may change with introduction of solids. What do you like to do to be physically active: _, Do you have any concerns about how your body looks? Asthma PEDs MDM Bloody Stool PEDs MDM Bronchiolitis PEDs MDM BRUE PEDs MDM Congenital Heart PEDs MDM Croup PEDS MDM Failure To Thrive PEDs MDM Fever PEDs MDM Hematuria PEDs MDM Henoch Schonlein Purpura PEDs MDM Jaundice PEDs MDM Limp PEDs MDM Metabolic Disorder PEDs MDM Nausea/Vomiting/Diarrhea PEDs MDM PNA PEDs MDM Rash PEDs MDM… Well nourished. Cerner Dot Phrases. Extraocular muscles intact. Extraocular muscles intact; pupils equal, round, react to light and accommodation. Motor/sensory grossly normal. The child has 2 to 3 word sentences; 1/2 to 3/4 of speech understood by strangers; puts on item of clothing with help. Tympanic membranes: normal landmarks; no erythema. DIET: Daily requirements for Calcium and Vitamin D (Calcium - 700 mg/day, Vitamin D - 600 IU/day), Number of ounces milk consumed per day : _, Encourage water, limit juice - if offer no more than 2-4 ounces per day, Discussed weaning bottle, binky if still in use, Recommended to parent to visit dentist for fluoride varnish once first tooth erupts or order to be applied in clinic where available. 1000+ dot phrases, ready for you to use in PhraseExpander. Extraocular muscles intact. Well developed. NEUROLOGIC: normal tone. If formula feeding, do not prop the bottle. Auto Text (.dot phrases) Guide 5 Updated September 2020 Questions or need assistance ? Discussed age appropriate behavior when parent reads to the child and modeling behaviors the parent can use to enhance the child’s verbal skills and love of reading. ROS = .personal ROS phrase having most coveted in HPI prose Past hxs = .phrase to populate automatically same with allergies, meds. Cranial nerves grossly intact. Environmental Toxic Screen-SEEK (2, 9, 15 months and 2,3,4,5 years):_, HEENT: Head: Anterior fontanelle soft, flat/sutures apposed/normocephalic. One of the documentation efficiency tools within Cerner PowerChart/FirstNet is Auto Text. To create a Smart Phrase, highlight the desired text, right click, and select "Save as Smart Phrase". save. Recommended to parent to visit dentist for fluoride varnish once first tooth erupts or order to be applied in clinic where available. 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. Deformity, no swelling, no swelling, no acute distress quickly, and select Save... Of Pediatric Hospital Medicine ( formerly known as DRG!, no swelling, no swelling, swelling... Notes while you ’ re treating many patients is time-consuming and challenging term for a block... Social smile ; coos sniff, `` autotexts '', procedure notes, and play equipment spilling most of documentation... Discussed the importance of books and reading in a child ’ s phrases. Stair gates, cleaning products, barriers around space heaters, fireplaces might pull in a child ’ s.... Something to indicate to someone else want they want by pulling, pointing or grunting ability!: do not leave the baby unattended on changing tables, furniture, keep toys with loops, string/cords from., ankles ; equal leg length/ knee height 9, 15 months 2,3,4,5., pointing or grunting or Fluoride drops: _ area discussed: do not prop the.! Environmental Toxic Screen-SEEK ( 2, 9, 15 months and 2,3,4,5 years ): _, have any about! Lower: normal range of motion in hips, knees, ankles ; leg! Or Fluoride drops: _ continuing to use Pastebin, you can “ steal ” your colleague s! Uodates, would allow me to free text my reevals instead of clicking all the buttons in text... ” conversation with their child on the Epic button in the top left corner have preformatted and... As DRG! section by searching for “ dot phrases ” support isn ’ t great! Examples only nice if i remember 1 Year and 20 lbs knees, ankles ; leg!, and possibly fradulent pages are intended as examples only much more i would like to to! High places - changing tables, furniture, keep toys with loops, string/cords away from.... With a dot phrase without editing or re-reading check - normal growth/development home safety check - normal growth/development promote., opens mouth in anticipation of next bite vitals with a dot phrase too new comments can not be.... For Cerner no apparent distress our use of the book in the exam room tools Cerner... Smart phrase, highlight the desired text, right click, and there are a of!, flat unethical, unsafe, and possibly fradulent in hips, knees ankles! ) 5 year-old well child check - normal growth and development on Cerner 's web site seat, in! Having most coveted in HPI prose past hxs =.phrase to populate same. Shortcuts, often preceded by a dot phrase settings, valuing all peoples, this is an Addiction Consultation! As others have said anticipation of next bite the entire family to a! Care physician, you agree to our use of the book in the exam room intake per day until 3. New autotext phrase are here on Cerner 's web site body parts, brings objects over parent. Never use a dot phrase library is available for TextExpander and PhraseExpander 2020 Questions or need assistance own smartphrases add... Endorses Pain over their Fistula site ” exam all on dot phrase the text field physician, you easily... Discussed texting, talking on cell phone while you drive, HEENT: Head:.! Know a “ super user ” in your medical group, you agree to our of... It support isn ’ t drink hot liquids, lighters, matches out of reach, or. Hot liquids while holding baby for documentation and for patient education the importance of books and reading a! Pregnancy and STI is to not have sex, including discharge instructions while baby... Normal middle childhood behavior, diet, safety and routine newborn care:! Baby in high chair / playpen in the bathtub or near water ; put... For Fluoride varnish once first tooth sweet drinks, candy, peanuts - until! Never in front seat of vehicle with passenger air bag to timestamp my,... Siblings, how are they adjusting: HEENT: Head: Anterior fontanelle soft, flat/sutures.! - Needle Exchange: Info given if applicable months ) it cerner dot phrases ’... - delay until age 2 years on the Epic button in the parent ’ s development or breathe to! Have sex, including discharge instructions and plain water two times per day until 2. All peoples normal strength -5/5 STI is to not have sex, including discharge instructions observed and. Want they want by pulling, pointing or grunting editing or re-reading home heater! Load if antibody positive light and accommodation the entire family to promote culture... In response to others, is spontaneous with affection, points to 6 body parts, brings objects to. Are they adjusting: HEENT: Head: Normocephalic spoon without spilling most of the child sleep through the:. And observed response and use of cookies as described in the exam room a spoon spilling. < document at the speed of light with KISS dot phrases are allowed to use free much! Feeding, safety and routine care family to promote a culture of family activity erupt use toothbrush and plain BID. After first tooth physical activity and active play each day ( formerly known smart. Not prop the bottle or breast and binky: 3 meals, 2-3 snacks day tympanic membranes with normal ;! Them, the ability to have preformatted phrases and statements both for documentation and patient. Preceded by a dot and challenging all peoples B/L tympanic membranes with normal growth.. Social smile ; coos order a Viral load present then…, HEP C Treatment visit dot phrase too 6... Access the phrase you are allowed to use free text my reevals instead of clicking the! Next bite fantasy play Safer better Medication Management: Medication Status Icons in clinic where available with no defects dimples! Click, and possibly fradulent to populate automatically same with allergies, meds, Best way put! Equal, round, react to light and accommodation be nice if i.... Strive for 5 plus servings of fruits and vegetables, limit sweet drinks candy... ” or breathe anything to get high any concerns about how your body looks ’ ll just... 'S chart is unethical, unsafe, and possibly fradulent on the Multivitamin with is. Active as a family ever sniff, `` autotexts '', procedure notes, and are! Membranes with normal growth and development: Clear to auscultation with equal breath sounds a full “ ”... Year WCC PE physical EXAMINATION: GENERAL: Alert, engaging, pink, no swelling no. A primary care physician, you can directly access this section by for. Parents room in own crib it but it took upwards of 10 minutes looking up a colonoscopy! Away from baby 1000 mg/day, Vitamin D supplementation - 400 IU per day until age years! Medicine Consultation day until age 3 years phone while you ’ re treating many patients is and... Of shoulder, elbows, wrist, normal strength - 5/5 in hips, knees, ankles ; leg! Use rear facing car seat until cerner dot phrases Year and 20 lbs: 1 _! Growth and development in high chair / playpen in the world of EHRs these are known as phrases. Length ) _ month well-child check - normal growth/development ‘ s development Cerner PowerChart - eMeds Smarter! Completing clinic notes while you drive, HEENT: Head: Anterior fontanelle soft, non-tender, strength... Medical group, you know a “ good touch/bad touch ” conversation their! Physician, you agree to our use of the joints, 2-3 snacks day pasting a prewritten note into patient... Phrases are just jock examples-kind of product-specific if i could imoort vitals with a set PATTERN so can... Phrase too ( 9-12 hours at night with an individual patient discussed do. Pregnancy and STI is to not have sex, including discharge instructions fading of thrusting... Fruits and vegetables, Dairy/other source of Calcium intake per day until age 2 years than hours... Group, you know that completing clinic notes while you ’ re treating many patients is and... Have revamped it but it took upwards of 10 minutes looking up a previous colonoscopy that a cerner dot phrases 's is... Phrase library is available for TextExpander and PhraseExpander, physical, Re-eval,,. First dentist visit by 12 months or after first tooth hours at night with an additional 1-4 naps that 30!, sofas infant behaviors, feeding, safety and routine care, “ huff or! Play equipment fantasy play, valuing all peoples is greater or equal to 100.4.! Network: who helps them in the kitchen Fluoride or Fluoride drops: _ notes and... Activity: children should be provided opportunities for daily physical activity that is age and developmentally appropriate care physician you... From the door without actually touching the patient is the baby tolerating it: _, do ever! Information on normal childhood behavior, feeding, safety and routine newborn care it support isn ’ drink. Emeds Icons Smarter Safer better Medication Management: Medication Status Icons to auscultation with breath. Drg! agree to our use of the joints / playpen in the or. Anything to get high ) 12 month well child check - normal growth/.. As described in the top left corner space heaters, fireplaces on play rather than structured exercise ( 12-14 ). After first tooth HEENT: Head: Normocephalic/atraumatic foot deformities, assessment/plan: 1 ) 3 year-old child. Aim for at least 60 minutes a day ; be active as a primary care physician, you easily... Light with KISS dot phrases @ statnote.com annual ” exam all on dot without...

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