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Thread: IMG SURVIVOR surving Intern year part 2

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    IMG SURVIVOR surving Intern year part 2

    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 04:33 PM.
    Moderator: USMLE AND Residency Forums.

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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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