Commonly Used Dot Phrases for Emergency Medicine (Epic, Cerner, generic)

This is a collection of my 20 most commonly used dot phrases. These are specific to me and the way I document.

As always, these can be customized to fit your style — you can use these as a framework and make changes as needed. They can also be used across any EMR, although I did include some specific use-cases for Epic.

Check out the other templates/documentation products on my shop & let me know if you’re interested in a bundle option!

IMPORTANT: I am not a medicolegal expert and these are combinations of things that I’ve learned from training and from reading medmal in the past few years. As always, be very careful with templates and make sure you edit it according to your patient/situation. Never leave in “A&Ox4” on a patient that is intubated and sedated.

Please check out my blog posts on documentation tips (here) and how to set up your own differential diagnosis dropdown in Epic (here).

PHRASES INCLUDED:

1. Discharge
2. Observation
3. Admission
4. Transfer
5. Expired
6. AMA
7. Medical clearance for crisis
8. Elopement
9. Sobriety discharge
10. Stitches (education)
11. Antibiotics (education)
12. Basic/”visual” physical exam (aka focused physical)
13. Resuscitation/death exam
14. Full neuro exam
15. EKG
16. Chest X-ray
17. Tamiflu
18. Social determinants of health
19. Critical care time
20. Sign out (received and endorsed)