PLEASE DON'T ASSUME YOUR NOTE TEMPLATES ARE UPDATED, BECAUSE TRUST ME THAT MOST OF THEM ARE NOT!!!

Here are the MOST UPDATED note templates that I would like you to use. Feel free to format them somewhat to your liking but DO NOT delete things in there as much of these are templated to gather data for research. So when it asks for "most recent latch score," give me a score, or an N/A. Don't change to "feeding well." We can't use that for research. As well, please refrain from using a million of these little smart phrase things that pull in information into the note, as much of it is redundant and useless - trust me, that if you don't have time to physically plop the Apgars into a note, then we have much bigger issues to deal with in your time management. If you aren't sure where to find all the info your template is asking you for, please ask!

For the Newborn Info, you should be able to find most of the info you need in the Newborn Flowsheet (under the Woman's Health View on the Dark Side menu). The hearing screen and CCHD screen results will be in Results Review under "Provider Assessments View", and the number of wet and dirty diapers, and the number of feeds will be in the Is and Os (though better to just ask the parents since the Is and Os not always appropriately charted. If not sure where to find something, ask me...do not put "not found" or "not charted." Even if I'm not the one signing the note. I'm a stalker. The jig will be up and I WILL find you!

If you have trouble downloading this document from here, let me know and I will email it out to you.

Types of Note Templates to Use in Cerner:

• OB H&P and Triage Note - use the OB History and Physical Template; do NOT use progress note or free text. It pulls in all the deliveries and such that the nurses have put in there already, as well as due date, what dating is by, etc.
• Newborn H&P - Free Text Template. Everything you should need is in the smart template, so no need for anything else. Seriously...nothing else.
• Labor Note - use the Progress Note drop down, and the free text template. You should have a smart phrase for regular, GDM, and PIH labor notes (see below!) Now if you are doing repeated notes on a patient, you can addend onto the same note - just put "10:30 Progress Note" and then write your next note at the bottom. You can do that for your OWN notes. Once a new resident is writing a note, start a new progress note.
• Progress Note - for Mom or for Baby, use the Progress/Soap Note Template. If you have smart templates set for the HPI, ROS, Exams, A&P then it's super easy and has everything you need in there. And for baby progress notes, the "24 hour concerns" part is your HPI...don't just put "none." If literally no concerns, at least put "Doing well - no major concerns from parents or nursing. Feeding, voiding, and stooling appropriately."
• Delivery/Circ/Cesarean/Tubal/D&C Note - should be a procedure note in the drop down (NOT PROGRESS NOTE), and then use a smart phrase for your template.
• Discharge Summary - for Mom or for baby, use the Free Text Template with the smart template below. You should not need to use the Discharge Summary template as again you get redundant information, I personally think they look ridiculous, and we lose our "high yield" note with the extra fluff they put in there. Plus it's more work for you.