NOTES AND ORDERS

 

ADMISSION / TRANSFER ORDERS

ADMIT

Floor, Service, Attending, Resident, Intern/AI

DIAGNOSIS

List in order of priority

CONDITION

good / stable / fair / guarded / critical, etc.

VITALS

q4o/ q shift / per routine

ACTIVITY

ad lib / bed rest / up to chair, etc.

ALLERGIES

List; if none then NKDA = “no known drug allergies”

NURSING

List everything that you want the nursing staff to do, i.e. “ins and outs q shift”, “bed to telemetry”, “elevate head of bed”, “change dressing bid”, “foley to gravity”, etc.

DIET

NPO / regular / clear liquids / ADA / heart healthy, etc.

IV FLUIDS

Type of fluid at rate for # bags

MEDS

List all medications

LABS

CBC, BMP, ABG, EKG, urinalysis, CXR – PA and lateral, etc.

SPECIAL

Physical therapy, diabetic educator, dietician consult, etc.

CALL IF

Temp > 101 or < 96, HR > 120 or < 60, RR > 30, BP > 160/90 or < 85/60

 

DISCHARGE SUMMARY

ADMISSION/DISCHARGE DATES

 

ADMISISON/DISCHARGE DIAGNOSES

List in order of importance

SERVICE

Service, Attending, Resident, Intern/AI

CONSULTS

Service, Attending physician, Date

PROCEDURES

Procedure name, Date, Results (this includes ABG, CT, MRI, Echo, biopsies and pathology results, etc.)

HISTORY and PHYSICAL

“See Admission History and Physical”

COURSE

List problems in order of importance and a brief summary of hospital course, including status of problem at discharge.

CONDITION

good / stable / fair / guarded / critical, etc.

DISPOSITION

Discharged to home, nursing home, etc.

MEDICATIONS

Discharge medications with dosage, etc.

INSTRUCTIONS

Activity, diet, dressing care

FOLLOW-UP

Follow-up appointments with doctor on date

 

PROGRESS (“SOAP”) NOTES

Subjective

Patient’s status overnight, including complaints and interval change (“no chest pain past 24 hours,” etc.), as well as nursing comments.

Objective

Vitals – Temp, Tmax, BP range, HR, RR, O2 sat, ventilator settings; Ins/Outs – IV/PO intake; urine/NG suction/drain volume, #BM/emesis; Physical exam; Labs, imaging, etc.

Assessment/

Plan

 

Summarize the patient in one sentence – “63 yo wm with history of CHF, HTN, COPD presenting with chest pain and SOB.”   Provide problem list and what is being done about problem in order of importance.

 

PROCEDURE NOTE

PROCEDURE

 

PERMIT

Procedure, benefits, risks (including those of bleeding, infection, injury, anesthesia), and alternatives explained to patient who voiced understanding of the information and agreed to proceed.  Permit signed and on the chart.

INDICATION

Meningitis, pleural effusion, venous access, ascites, etc.

PHYSICIAN(S)

 

DESCRIPTION

Area prepped and draped in a sterile fashion.  (Local, spinal, etc.) anesthetic administered using (cc medication).  Describe technique including body location, instruments, etc.

COMPLICATIONS

(Hopefully none)

EBL

(estimated blood loss in cc)

DISPOSITION

Patient resting comfortably, breathing non-labored, incision clean, dry, and intact, etc.

 

 

HISTORY AND PHYSICAL

cc:

Patient’s complaint in his/her own words

History (Hx) of

Present Illness:

Chronological order of time / place of symptoms, onset, duration, frequency, location, quality, quantity, severity, aggravating and alleviating factors, associated symptoms, medicines taken, relevant laboratory values (if transferred from outside hospital), pertinent negatives.

Past Medical Hx:

Previous diagnoses and date of diagnosis, complications of illnesses; childhood illnesses and immunizations if pediatric; most recent hospitalizations; results of screening tests (echo, Pap smear, mammogram, cholesterol)

Past Surgical Hx:

Operation(s), date(s), reason, outcome, blood transfusions, complications

Family Hx:

Age, health, death of parents, siblings, spouse, children.  Ask about diabetes, heart disease, hypertension, stroke, cancer, bleeding disorders, asthma, arthritis, tuberculosis, seizures, mental illness, symptoms of presenting illness.

Social Hx:

Current residence, education, employment, persons at home, diet, exercise; tobacco, alcohol, or drug use – amount, frequency, duration of each

Medications:

Name, dose, frequency, reason for taking, complaint?

Allergies:

Medications and reactions to those medications

Review of Systems:

1.       General: weight change, fatigue, weakness, fever, chills, night sweats.

2.       Skin: skin, hair, nail changes, itching, rashes, sores, lumps, moles.

3.       HEENT: trauma, headache location/frequency, nausea, vomiting, visual changes, diplopia, hearing loss, tinnitus, vertigo, earache, rhinorrhea, stuffiness, sneezing, allergy, epistaxis, bleeding gums, hoarseness, sore throat, swollen neck.

4.       Breasts: skin changes, masses/lumps, pain, discharge, self exams?

5.       Lungs: shortness of breath, wheezing, cough, sputum, hemoptysis, pneumonia, asthma, bronchitis, emphysema, tuberculosis, last CXR.

6.       Heart: hypertension, murmurs, angina, palpitations, dyspnea on exertion, orthopnea, paroxysmal nocturnal dyspnea, edema, last EKG.

7.       GI: appetite, nausea, vomiting, indigestion, dysphagia, BM frequency/change, diarrhea, constipation, hematemesis, melena, hematochezia, hemorrhoids, abdominal pain, jaundice, hepatitis.

8.       Urinary: frequency, hesitancy, urgency, polyuria, dysuria, hematuria, nocturia, incontinence, stones, infection.

9.       Genital: STD history/treatment, contraception, sex interest and function; male = penile discharge/sores, testicular pain/masses, hernias; female = menarche, period regularity, frequency, duration, dysmenorrhea, last period, itching, discharge, sores, pregnancies and complications, miscarriages, abortions, birth control, menopause, hot flashes/sweats.

10.   Vascular: edema, claudication, varicose veins, thromboses/emboli

11.   Musculoskeletal: muscle weakness, pain, joint stiffness, range of motion, instability, redness, swelling, arthritis, gout.

12.   Neurologic: loss of sensation, tingling, tremors, weakness, paralysis, fainting, blackouts, seizures.

13.   Heme: anemia, easy bruising/bleeding, petechiae, purpura, transfusions

14.   Endocrine: heat/cold intolerance, excessive sweating, polyuria, polydipsia, polyphagia, thyroid, diabetes.

15.   Psychiatric: mood, anxiety, depression, tension, memory

Physical Exam:

1.       Vitals: temperature, BP, HR, respirations, SaO2, height, weight

2.       General: sex, race, state of health, stature, development, dress, hygiene, affect

3.       Skin: scars, rashes, bruises, hair consistency, nail pitting, stippling.

4.       HEENT: size/shape of head, trauma?, pupil size, shape, and reactivity, conjunctival injection, scleral icterus, fundal papilledema/hemorrhage, extraocular movements, visual fields and acuity, gross auditory acuity, nasal discharge and mucosa color, tonsilar enlargement, moistness of mucous membranes, pharyngeal exudate.

5.       Neck: masses, range of motion, tracheal deviation, thyroid size, lymphadenopathy?

6.       Breasts: skin changes, symmetry, tenderness, masses, dimpling, discharge

7.       Lungs: chest symmetry with respriations, wheezes, crackles, fremitus, whispered pectoriloquy, percussion, diaphragmatic excursion, egophony.

8.       Heart: rate, rhythm, murmurs, rubs, gallops, clicks, precordial movements.

9.       Abdomen: shape, scars, bowel sounds, consistency (soft vs. firm), tenderness, rebound, masses, guarding, spleen size, liver span, percussion (tympany, shifting dullness), CVA tenderness.

10.   GU: male – rashes, ulcers, scars, nodules, induration, discharge, scrotal masses, hernias; female – external genitalia, vaginal mucosa and cervix: look for inflammation, discharge, bleeding, ulcers, nodules, masses, internal vaginal support, bimanual/rectovaginal palpation of cervix, uterus, ovaries

11.   Rectal: sphincter tone, prostate consistency and size, masses, hemoccult.

12.   Vascular: carotid, radial, femoral, popiliteal, posterior tibial, dorsalis pedis pulses, carotid bruits, jugular venous distension, edema, varicose veins.

13.   Musculoskeletal: atrophy, weakness, joint range of motion, instability, redness, swelling, tenderness, spine deviation, gait.

14.   Neurologic: see “Neurology” for full neurologic exam.

Labs:

Fluid balance, hematology, urinalysis, coagulation panel, cultures, EKG, any imaging results, etc.

Assessment/Plan:

Differential diagnosis – state each possibility and reasons for inclusion or exclusion from history, physical, and lab results; medications to be started, procedures and additional labs to be done, consults to be obtained, etc.