Daily

ID: One Liner
POD#
HD#
Procedure: s/p TAH/BSO, Staging, D&C
For: Postmenopausal bleeding, pelvic mass, ectopic pregnancy,
SUBJECTIVE
Ask the patient about pain,
Character of pain
Onset
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 (is it regular, liquid?)
OBJECTIVE
O2 Sat? On Room Air? 2L? 3L?
Add any imaging not previously included since last note.	
IF a new note, add most recent + relevant imaging available in the chart
Add Up the previous day’s I/Os
ALWAYS update POD day from the previous note
Update labs / add-in most recent + relevant labs
Decrease the font siaze to 8-10: Labs, Imaging & Procedures
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? 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?
E.g Diabetes, HTN, can affect post-op healing
Presentation
One-liner.
Why the patient is here.
What in the “subjective” changed.
Pain
BM
Ambulating
What in the “objective” had changed
Vitals	
Physical Exam
I/O
Labs
Imaging
What we are doing for the patient.
What in “Plan” changed.
Discharge plan.