Daily

[_] ID:             _____________________
[_] Room:           _____________________
[_] POD | HD#   1       2       3       4       5       6       7       8       9   10  11  12
[_] PROCEDURE       s/p _________________________________
[_] INDICATION      For: ____________________________________________

    C H A R T . R E V I E W

--------VITALS
    
--------[_] BP?               _____ / ______        [_] PULSE?            ___________ 
--------[_] HR?               ___________           [_] O2 Sat?           ___________ 
                                                    [_] On Room Air     [_] 2L      [_] 3L

============================================================
==================S U B J E C T I V E=======================
============================================================

************************************************************
------------------I N T E R V I E W-------------------------
************************************************************

[_]--------Ask the patient about pain-------- [ Y | N ]
[_]--------Character--------------------------[___]Sharp        [___]Dull        [___]Crampy  [___]Achey | 
[_]--------Onset------------------------------[___]Day(s)       [___]Week(s)     [___]Year(s)
[_]--------Duration
[_]--------Intensity
[_]--------Exacerbating factors
[_]--------Relieving factors:
[_]--------Symptoms associated with pain
[_] Is the patient post-op? 
[_] Ask about flatus, bowel movements,
[_] Ask about nausea and vomiting
[_] Ask about any shortness of breath
[_] Ask about fever or chills
[_] Ask if the patient is tolerating current diet 
[_]----------------regular
[_]----------------liquid

============================================================
================== O B J E C T I V E =======================
============================================================-------------------------------------

    VITALS
    1.    [_] BP?               _____ / ______ 
    2.    [_] PULSE?            ___________ 
    3.    [_] HR?               ___________ 
    4.    [_] O2 Sat?           ___________ 

-------------------------------------
--------2.    [_] On Room Air?    
--------3.    [_] 2L? 
--------4.    [_] 3L?
---LABS
=================================================================
[_]     5.      CHECKED [_]
            
[_]             NONE            LABS ORDERED YESTERDAY 

[_]

--------RESULT 

                                    --------------------------------------------------

[_]     

--------RESULT 

                                    --------------------------------------------------

[_]                                                              

--------RESULT 

                                    --------------------------------------------------

[_]                                                              

--------RESULT 

                                    --------------------------------------------------
                                    
    IMAGING
[_]     6.      [_] Imaging not previously included since last note	
    ----------------------------------------------



    //////////////
    ADD TO NOTE
    //////////////

    Labs, Imaging & Procedures
        Update 
            Add
[_]            Most Recent 
[_]           Relevant labs

    -----------------------------------------------
    * * * IF a new note * * *  
        add imaging
[_]         most recent
[_]         relevant 
[_]     Add Up the previous day’s I/Os _________________
[_]     update POD day from the previous note
[_]     Decrease the font siaze to 8-10: 

    ASSESSMENT
    Age
HD# or POD# s/p _ for
Status: improving, doing well, stable 

PLAN
////

Why the patient is on our service

Where are we in the plan?

What has been completed since last note? Y / N

When?

What has not been completed since last note? 

-
_____________________

-
_____________________

-
_____________________

Why?


What, if anything, do we need to reach completion?

What relevant chronic problems is the patient receiving treatment for?

                                    Diabetes
                                    
                                    HTN
                                    

P R E S E N T A T I O N - O N E . L I N E R
////////////////////////////////////////////

Why the patient is here.
-----------------------------------------------------------------





==================================================================
* * * * What in the “subjective” changed * * * * *
==================================================================

Subjectively 

            (name) ____________ 

                            has had       
                            |
                            ---------->         [_]     no change in    
                            |        
                            |--------->                 a change in:    [_] 
                                        
                                               
                                                [_]         Pain?       [_]
                                                [_]         BM?         [_]

-----------------------------------------------------------------
- Ambulating?
==================================================================
What in the “objective” had changed
==================================================================
Y (There were changes in) / N (No Change In)

Y / N               Vitals?	        
-----------------------------------------------------------------
Y / N               Physical Exam?    
-----------------------------------------------------------------
Y / N               I/O?
-----------------------------------------------------------------
Y / N               Labs?             
-----------------------------------------------------------------
Y / N               Imaging?          
-----------------------------------------------------------------
////////////////////
O B J E C T I V E
//////////////////
OBJECTIVELY 

            (name) ____________ 

                            has had       
                            |
                            ---------->         [_]     no change in    
                            |        
                            |--------->                 a change in:    [_] 
                                        
                                               
                                                [_]         Pain?       [_]
                                                [_]         BM?         [_]

-----------------------------------------------------------------

What we are doing for the patient.

What in “Plan” changed.

Discharge plan.

QUESTIONS

What we are doing for the patient.

What in “Plan” changed.