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Thread: IMG SURVIVOR surving Intern year part 2

  1. #1
    IMG SURVIVOR's Avatar
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    IMG SURVIVOR surving Intern year part 2

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    You can find this info in any book.
    Daily progress notes should summarize developments in a patient's hospital course, problems that remain active, plans to treat those problems, and arrangements for discharge. Progress notes should address every element of the problem list.


    Progress Note

    Date/time:

    Subjective: Any problems and symptoms of the patient should be charted. Appetite, pain, headaches or insomnia may be included.

    Objective:General appearance. Vitals, including highest temperature over past 24 hours. Fluid I/O (inputs and outputs), including oral, parenteral, urine, and stool volumes. Physical exam, including chest and abdomen, with particular attention to active problems. Emphasize changes from previous physical exams.

    Labs: Include new test results and circle abnormal values.

    Current medications: List all medications and dosages.

    Assessment and Plan: This section should be organized by problem. A separate assessment and plan should be written for each problem.
    Last edited by IMG SURVIVOR; 03-08-2010 at 03:33 PM.
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    why even bother with the obvious. Just know where you are need it and where you can help the most.

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    Adm check list

    1. Call and request old chart, ECG, and X-rays.

    2. Stat labs: CBC, Chem 7, cardiac enzymes (myoglobin, troponin, CPK), INR, PTT, C&S, ABG, UA.

    3. Labs: Toxicology screens and drug levels.

    4. Cultures: Blood culture x 2, urine and sputum culture (before initiating antibiotics), sputum Gram stain, urinalysis.

    5. CXR, ECG, diagnostic studies.

    6. Discuss case with resident, attending, and family.
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    why even bother with the obvious. Just know where you are need it and where you can help the most.

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    Discharge note

    The discharge note should be written in the patient’s chart prior to discharge.

    Discharge Note

    Date and time:

    Diagnoses:

    Treatment: Briefly describe treatment provided during hospitalization, including surgical procedures and antibiotic therapy.

    Studies Performed: Electrocardiograms, CT scans.

    Discharge Medications:

    Follow-up Arrangements:
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    why even bother with the obvious. Just know where you are need it and where you can help the most.

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    Discharge summary

    Patient's Name and Medical Record Number:

    Date of Admission:

    Date of Discharge:

    Admitting Diagnosis:

    Discharge Diagnosis:

    Attending or Ward Team Responsible for Patient:

    Surgical Procedures, Diagnostic Tests, Invasive Procedures:

    Brief History, Pertinent Physical Examination, and Laboratory Data: Describe the course of the patient's disease up until the time that the patient came to the hospital, including physical exam and laboratory data.

    Hospital Course: Describe the course of the patient's illness while in the hospital, including evaluation, treatment, medications, and outcome of treatment.

    Discharged Condition: Describe improvement or deterioration in the patient's condition, and describe present status of the patient.

    Disposition: Describe the situation to which the patient will be discharged (home, nursing home), and indicate who will take care of patient.

    Discharged Medications: List medications and instructions for patient on taking the medications.

    Discharged Instructions and Follow-up Care: Date of return for follow-up care at clinic; diet, exercise.

    Problem List: List all active and past problems.

    Copies: Send copies to attending, clinic, consultants.
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    why even bother with the obvious. Just know where you are need it and where you can help the most.

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    Writing Rx

    • Patient’s name:

    • Date:

    • Drug name, dosage form, dose, route, frequency (include concentration for oral liquids or mg strength for oral solids): Amoxicillin 125mg/5mL 5 mL PO tid

    • Quantity to dispense: mL for oral liquids, # of oral solids

    • Refills: If appropriate

    • Signature
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    rokshana is offline Member Guru 11644 points
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    i wouldn't recommend circling abnormal labs values... you circle it that means you need to do something about it...and while the value may be abnormal, you may not do something about it....but it may get questions if there is any legal action in question...yes it is cya, but realize that your note is now a legal document...it will need to be able to withstand such scrutiny.
    Endocrinology, Diabetes and Metabolism Attending
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    ValueMD-the place "where nothing makes sense, but everything is related-fellow vmd'r gabon

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    Quote Originally Posted by rokshana View Post
    i wouldn't recommend circling abnormal labs values... you circle it that means you need to do something about it...and while the value may be abnormal, you may not do something about it....but it may get questions if there is any legal action in question...yes it is cya, but realize that your note is now a legal document...it will need to be able to withstand such scrutiny.
    Thanks for the heads up.
    Naijaman24 likes this.
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    why even bother with the obvious. Just know where you are need it and where you can help the most.

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    DrGeorge is offline Newbie 510 points
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    Does it apply for all residency types? ( IM, SURG, FP) ??

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    mellisa2011 is offline Junior Member 510 points
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    this post really helps

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    Ife
    Ife is offline Newbie 510 points
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    Thanks for the tips.

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