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.
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