Daily Note

[date format="DD, MM d, yy"]



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[link memo="ID" mark="ID"]
.    [link memo="Updates" mark="updates"]
.    [link memo="tele" mark="tele"]

[link memo="S" mark="subjective"]
.    [link memo="ros" mark="ros"]

[link memo="O" mark="objective"]
.   [link memo="Vitals" mark="vitals"]
.   [link memo="physical exam" mark="physical exam"]
.   [link memo="I&O" mark="I&O"]
.   [link memo="Labs" mark="labs"]

[link memo="calculate" mark="calculate"]


[mark name="ID"] [link memo="Top" mark="Top"]
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I D
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Name: [text default=""]
Age: [text default=""]
Date of Admission:      [date]
Initial Chief Complaint: [text default=""]
# CHIEF COMPLAINT: [select name="variable_16" value="***|A|Abdominal Pain|Alcohol Withdrawal|Altered Mental Status / Confusion|B|Bilateral Leg Pain|C|Chronic Obstructive Pulmonary Disease (COPD)|Confusion / Altered Mental Status|D|Diabetes Mellitus|E|Ethanol abuse|F|G|H|Headache|I|Intractable Headache||Intractable Back Pain|J|K|L|Left Leg Pain|M|N|Nausea|Nausea + Vomiting|O|P|Paresthesia|Pulmonary Exacerbation Secondary To Cystic Fibrosis|Q|R|Right Leg Pain|S|Shortness of Breath (SOB)|Shortness of Breath (SOB) Secondary To Congestive Heart Failure Exacerbation|Shortness of Breath (SOB) Secondary To Suspected Congestive Heart Failure Exacerbation|Sickle Cell Crisis|T|Type I Diabetes|Type II Diabetes|U|V|Vaso-Occlusive Crisis|W|X|Y|Z"] #

Admission Diagnosis:    [text default=""]
ICU Day:                [text default=""]
ICU Diagnosis: [text default=""]
PMH: [textarea default=""]

[mark name="updates"] [link memo="Top" mark="Top"]


Patient is a [select name="variable_01" value="***|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64|65|66|67|68|69|70|71|72|73|74|75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98|99|100"] year old [select name="variable_02" value="***|female|male|man|woman"] hospital day [select name="variable_29" value="***|0|1|2|3|4|5|6|7|8|9|10|11|12|13|14|15|16|17|18|19|20|21|22|23|24|25|26|27|28|29|30|31|32|33|34|35|36|37|38|39|40|41|42|43|44|45|46|47|48|49|50|51|52|53|54|55|56|57|58|59|60|61|62|63|64|65|66|67|68|69|70|71|72|73|74|75|76|77|78|79|80|81|82|83|84|85|86|87|88|89|90|91|92|93|94|95|96|97|98|99|100"] [select name="variable_17" value="***|who presents with a chief complaint of|who is presenting with|who was admitted for|who was electively admitted for evaluation of|who comes in to clinic for follow up of|who comes in to clinic for follow up for"] [select name="variable_16" value=""] with a relevant past medical history significant for [checkbox name="variable_18" value="***|___A___|acute diastolic congestive heart failure (CHF)|acute kidney history (AKI)|acute midline back pain with sciatica|acute midline back pain without sciatica|acute subdural hematoma|alcohol abuse|alcohol use disorder|amphetamine abuse|anasarca|aneurysm (intracranial)|anemia|anemia due to blood loss|anemia due to chronic stage 4 renal failure|anti-phospholipid syndrome (APS)|anxiety|aortic valve stenosis|arthritis (osteoarthritis)|ascites due to cirrhosis|asthma|atrial fibrillation|avascular necrosis of the ***|avascular necrosis in bilateral hips|avascular necrosis of right humerus|avascular necrosis of left humerus|___B___|bacterial vaginosis (BV)|benzodiazepine abuse|___C___|cardiomyopathy|carotid stenosis (left)|carotid stenosis (right)|carpal tunnel syndrome (CTS)|cataracts|cataracts secondary to diabetes|cervical disk disorder|cervical radiculopathy|chronic abdominal pain|chronic anemia|chronic cough|chronic cough secondary to ACE inhibitor|chronic pain with long-term opiate medications|chronic obstructive pulmonary disease (COPD)|chronic insomnia|chronic kidney disease (CKD) secondary to type II diabetes|chronic insomnia|chronic kidney disease (CKD) secondary to type I diabetes|chronic renal allograft nephropathy|clostridium difficile infection|cocaine use|colonic polyps|colonic polyps status post removal in ***|cystocele (lateral)|cystocele (midline)|cyclic vomiting syndrome|cystic fibrosis|___D___|delirium|depression|diabetes type I|diabetes type II|diabetic nephropathy secondary to type I diabetes|diabetic nephropathy secondary to type II diabetes|diarrhea|drug seeking behavior|deep venous thrombosis (DVT)|deep venous thrombosis (DVT) of right leg|deep venous thrombosis (DVT) of left leg|diverticulitis|diverticulosis|___E___|eclampsia|emphysema|episode of syncope|episodes of syncope|episodic syncope|esophageal varices|essential hypertension|ethanol abuse|___F___|fall|___G___|gastritis|gastroesopheal reflux disease (GERD)|generalized abdominal pain|gilbert disease|___H___|heart failure with preserved ejection fractiom (HFpEF)|heart murmur|hemodialysis heroine use|herpes simplex virus(HSV)|history of atrial fibrillation|history of DVT in right leg|history of DVT in left leg|history of renal transplant|hypercholesterolemia|hyperglycemic episodes|hyperkalemia|hyperlipidemia (HLD)|hypernatremia|hyperparathyroidism|hyperparathroidism secondary to renal failure|hyperphosphotemia|hypertension (HTN)|hypertension (HTN) uncontrolled|hypoglycemic episodes|hypokalemia|hyponatremia|hypophosphatemia|___I___|incomplete bladder emptying|intracranial aneurysm|intractable back pain|___J___|___K___|kidney disease|___L___|lactic acidosis|liver disease|lung nodule seen on imaging study|___M___|major depressive disorder (MDD)|major depressive disorder (MDD) with mixed features| major depressive disorder (MDD) with psychotic features|malingering|metabolic acidosis|misscarriage in ***|___N___|nodular duodenitis|nodular duodenitis and scalloped appearing thicken small bowel|___O___|obstructive sleep apnea (OSA)|osteoarthritis|___P___| pancreatic cancer|pancreatitis|pancytopenia|panic attacks|parethesias|paroxysmal atrial fibrillation|pericardial effusion|pericardial effusions|peripheral artery disease (PAD)|personality disorder|placental insufficiency|poly-substance abuse|pre-eclampsia|pre-mature atrial contraction|primary prostatic cancer|primary prostatic cancer with metastasis|protienuria|pulmonary embolism|pulmonary hypertension|___Q___|___R___|rectocele|recurrent urinary tract infection (UTI)|retroperitoneal lymphadenopathy|___S___|scoliosis|secondary hyperparathyroidism of renal origin|shortness of breath (SOB)|sickel cell anemia|sickle cell disease|sickle cell disease with frequent admissions for pain control|sleep apnea|spontaneous bacterial peritonitis|stage 4 chronic kidney disease|stroke|stroke with residual right hemiparesis|stroke with residual left hemiparesis|subarachnoid hemorrhage (SAH)|subdural hematoma|syndrome of inappropriate antidiuretic hormone (SIADH)|systemic lupus erythematosus (SLE)|___T___|thrombocytopenia|tobacco use|type I diabetes|type II diabetes with complication|type II diabetes without complications|___U___|urinary retention|urinary retention secondary to benign prosthetic hypertrophy (BPH)|urinary tract infections (UTI)|ulnar nerve compression|___V___|venous thromboembolism (VTE)|___W___|wegner's granulomatosis|___X___|___Y___|___Z___"]. 

Other significant but non-pertinent past medical history includes: 

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U P D A T E S
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[textarea default=""]

[mark name="tele"] [link memo="Top" mark="Top"]
[comment memo="1.Check Tele"]

[comment memo="Any Events? Any VT?"]
[text default=""]
[comment memo="What was the event? VT? AFib?"]
[text default=""]
[comment memo="When?"]
[comment memo="Date"][date]
[comment memo="Name"][text default=""]
[comment memo="Results"][textarea default=""]

[text default=""]
[comment memo="For How Long"]
[text default=""]

[comment memo="Was Pt. Symptommatic?"]
[text default=""]

..d8888b..........................................
d88P..Y88b........................................
Y88b..............................................
."Y888b...........................................
...."Y88b.........................................
......"888........................................
Y88b..d88P........................................
."Y8888P"..ubjective .............................
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[mark name="subjective"] [link memo="Top" mark="Top"]

[textarea default="This morning, the patient reports feeling ''better''. Last pain score was 0/10. Reports an improved ''appetite and alertness''. Currently asymptomatic, tolerating current therapy w/o any reported side effects."]


# Patient states that they were was in their usual state of health until "[text name="variable_10" default=""]"

# Patient seen and examined this morning. [select name="variable_26" value="***|No overnight events.|Patient was in their usual state of health until ***| "]

# Patient [select name="variable_05" value="***|denies any acute complaints"].

# Patient [select name="variable_06" value="***|denies any general improvement since admission|denies any general improvement since yesterday|endorses a general improvement since admission|endorses a general improvement since yesterday|continues to deny any general improvement since admission|continues to endorse a general improvement from admission|continues to endorse generalized pain without any significant improvement from yesterday"]. 

# Patient [checkbox name="variable_19" value="***|ATTESTS TO|ABDOMINAL PAIN|CHEST PAIN|NAUSEA|SHORTNESS OF BREATH|VOMITING|"][checkbox name="variable_08" value="***|Patient denies any|abdominal pain|chest pain|nausea|shortness of breath|vomiting|"]. 

# Patient is currently is *** in pain**"[text name="variable_11" default=""]" and rated a "[text name="variable_12" default=""]" out of 10. 
- The pain is described as " dull "
- The pain is described as " sharp "
- The pain is described as " crampy "
- The pain is described as " an ache "
- The pain is described as " X "


[mark name="ros"] [link memo="Top" mark="Top"]
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R O S
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[textarea default="Otherwise negative except for mentioned in HPI"]


Constitutional
[checkbox name="variable_1" value="***|No complaints of fever or chills|! COMPLAINS OF CHILLS. No complaints of fever|! COMPLAINS OF FEVER. No complaints of chills.|! COMPLAINS OF FEVER & CHILLS."]

Eyes
[checkbox name"variable_2" value="***|No complaints of itching or burning|! COMPLAINS OF BURNING. No complaints of itching|! COMPLAINS OF ITCHING. No complaints of burning.|! COMPLAINS OF ITCHING & BURNING."]

Ears, Nose, & Throat
[checkbox name"variable_2" value="***|- No complaints of sore throat or nosebleeds|- No complaints of sore throat. ! COMPLAINS OF NOSEBLEEDS|! COMPLAINS OF SORE THROAT. No complaints of nosebleeds|! COMPLAINS OF SORE THROAT & NOSEBLEEDS.

Respiratory
[checkbox name"variable_3" value="***|No complaints of shortness of breath or wheezing.|- No complaints of shortness of breath. ! COMPLAINS OF WHEEZING|! COMPLAINS OF SHORTNESS OF BREATH. No complaints of wheezing|! COMPLAINS OF SHORTNESS OF BREATH & WHEEZING."]

Cardiovascular
[checkbox name"variable_4" value="***|No complaints of chest pain or edema.|No complaints of chest pain.|! COMPLAINS OF EDEMA.|! COMPLAINS OF CHEST PAIN. No complaints of edema.|! COMPLAINS OF CHEST PAIN & EDEMA."]

Gastrointestinal
[checkbox name"variable_2" value="***|No complaints of diarrhea or abdominal pain.| No complaints of diarrhea. COMPLAINS OF ABDOMINAL PAIN LOCALIZED TO (***).|COMPLAINS OF DIARRHEA (***# of times). No complaints of abdominal pain.| COMPLAINS OF DIARRHEA (***# of times) & ABDOMINAL PAIN LOCALIZED TO (***)."]

Genitourinary
[checkbox name"variable_5" value="***|No complaints of discharge, hematuria, or burning with urination|! COMPLAINS OF|VAGINAL DISCHARGE|PENILE DISCHARGE|HEMATURIA|BURNING WITH URINATION||Denies|vaginal discharge|penile discharge|hematuria|burning with urination"]

Musculoskeletal
[checkbox name"variable_28" value="***|No complaints of weakness, decreased range of motion, or back pain|! COMPLAINS OF|BACK PAIN|WEAKNESS IN LEFT ARM|WEAKNESS IN LEFT LEG|WEAKNESS IN RIGHT ARM|WEAKNESS IN RIGHT LEG|WEAKNESS IN UPPER EXTREMITIES BILATERALLY|WEAKNESS IN LOWER EXTREMITIES BILATERALLY||Denies|back pain|weakness in left arm|weakness left leg|weakness in right arm|weakness in right leg|weakness in upper extremities bilaterally|weakness in lower extremities bilatterally

Hematology & Lymph Nodes
[checkbox name"variable_27" value="***|No complaints of bleeding or bruising|! COMPLAINS OF|BLEEDING|BRUISING||Denies|bleeding|bruising"]

Immunologic
[checkbox name"variable_11" value="***|No complaints of rhinorrhea, sneezing, fever, or chills|! COMPLAINS OF|RHINORRHEA|SNEEZING|FEVER|CHILLS||Denies|rhinorrhea|sneezing|fever|chills"]

Endocrinology
[checkbox name"variable_14" value="***|No complaints of thirst, night sweats, significant weight gain or weight loss|! COMPLAINS OF|THIRST|NIGHT SWEATS|SIGNIFICANT WEIGHT GAIN|SIGNIFICANT WEIGHT LOSS|Denies|thirst|night sweats|significant weight gain|significant weight loss|significant weight gain or weight loss"]

Dermatological
[checkbox name"variable_8" value="***|No complaints of rashes, lesions, or ulcerations|! COMPLAINS OF|SKIN RASH|A LESION|LESIONS||Denies|skin rash|lesions"]

Neurological 
[checkbox name"variable_9" value="***|No complaints of numbness, tingling, or headache|! COMPLAINS OF|NUMBNESS|TINGLING|HEADACHE||Denies|numbness|tingling|headache"]

Psychiatric 
[checkbox name"variable_13" value="***|No complaints of anxiety, depression, suicidal ideation or homicidal ideation|! COMPLAINS OF|ANXIETY|DEPRESSION|SUICIDAL IDEATION|HOMICIDAL IDEATION||Denies|anxiety|depression|suicidal ideation|homicidal ideation"]


[mark name="objective"] [link memo="Top" mark="Top"]
..d88888b.........................................
d88P" "Y88b.......................................
888.....888.......................................
888.....888.......................................
888.....888.......................................
888.....888.......................................
Y88b...d88P.......................................
."Y88888P"..bjective..............................
 
 
[mark name="vitals"] [link memo="Top" mark="Top"]
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V i t a l s
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T   [text default=""]\[text default=""]\[text default=""]
HR  [text default=""]\[text default=""]\[text default=""]
BP  [text default=""]\[text default=""]\[text default=""]
P   [text default=""]\[text default=""]\[text default=""]
RR  [text default=""]\[text default=""]\[text default=""]
O2  [text default=""]\[text default=""]\[text default=""]

[textarea default=""]

[link memo="Top" mark="Top"] [mark name="physical exam"]

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P . E
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Gen:    [text default="laying in bed"]
        [text default="NAD"]
HEENT:  [text default="NC/AT"]
        [text default="EOMI"]
        [text default="PERRL"]
        [text default="MMM"]
        [text default="OP clear"]
Neck:   [text default="supple"]
        [text default="no cervical LAD"]
[text default="!        Mild JVD"]
Heart:  [text default="regular rate"]
        [text default="regular rhythm"]
        [text default="normal S1"]
        [text default="normal S2"]
[text default="!        Systolic murmur in LLSB."]
Pulm:   [text default="CTA B/L"]
        [text default="no wheezes"]
        [text default="no crackles"]        
        [text default="No nasal flaring"]
Abd:    [text default="soft"]
        [text default="non-tender"]        
        [text default="non-distended"]
        [text default="active bowel sounds"]        
        [text default=""]        
        [text default=""]
        [text default=""]
Exts:   No edema
        No clubbing
        [text default=""]
        [text default=""]
Neuro:  A&Ox4
        normal speech
        motor grossly intact
        sensory grossly intact
        [text default=""]
        [text default=""]
        

[textarea default=""]
[link memo="Top" mark="Top"][mark name="I&O"]
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I & O
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I   [text default=""] mL
O   [text default=""] mL
T   [text default=""] mL
UOP [text default=""] mL

[link memo="Top" mark="Top"][mark name="labs"]
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L A B S [link memo="Top" mark="Top"]
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C B C [link memo="Top" mark="Top"]

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Wbc [text default=""]\[text default=""]\[text default=""]
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Rbc [text default=""]\[text default=""]\[text default=""]
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Hgb [text default=""]\[text default=""]\[text default=""]
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Plt [text default=""]\[text default=""]\[text default=""]
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C H E M [link memo="Top" mark="Top"]

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K   [text default=""]\[text default=""]\[text default=""]

Ca  [text default=""]\[text default=""]\[text default=""]

Co2 [text default=""]\[text default=""]\[text default=""]

Cl  [text default=""]\[text default=""]\[text default=""]

Mg  [text default=""]\[text default=""]\[text default=""]

PO  [text default=""]\[text default=""]\[text default=""]

AG  [text default=""]\[text default=""]\[text default=""]

BUN [text default=""]\[text default=""]\[text default=""]

Cr  [text default=""]\[text default=""]\[text default=""]

GFR [text default=""]\[text default=""]\[text default=""]

Glu [text default=""]\[text default=""]\[text default=""]

A1c [text default=""]\[text default=""]\[text default=""]

PT  [text default=""]\[text default=""]\[text default=""]

PTT [text default=""]\[text default=""]\[text default=""]

INR [text default=""]\[text default=""]\[text default=""]

DD  [text default=""]\[text default=""]\[text default=""]

Lac [text default=""]\[text default=""]\[text default=""]

L F T 

AST     [text default=""]\[text default=""]\[text default=""]

ALT     [text default=""]\[text default=""]\[text default=""]

ALK     [text default=""]\[text default=""]\[text default=""]

DB      [text default=""]\[text default=""]\[text default=""]

IDB     [text default=""]\[text default=""]\[text default=""]

TB      [text default=""]\[text default=""]\[text default=""]

Alb     [text default=""]\[text default=""]\[text default=""]

Prot    [text default=""]\[text default=""]\[text default=""]

AMMONIA [text default=""]\[text default=""]\[text default=""]

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BLOOD GAS

PH      [text default=""]\[text default=""]\[text default=""]


PCO2    [text default=""]\[text default=""]\[text default=""]

PO2     [text default=""]\[text default=""]\[text default=""]

HCO3    [text default=""]\[text default=""]\[text default=""]

OXHGB   [text default=""]\[text default=""]\[text default=""]

CBXYHGB [text default=""]\[text default=""]\[text default=""]

METGB   [text default=""]/[text default=""]/[text default=""]

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M i c r o [link memo="Top" mark="Top"]
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I M A G I N G [link memo="Top" mark="Top"]
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X r a y [link memo="Top" mark="Top"]
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C t [link memo="Top" mark="Top"]
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E c h o / U s [link memo="Top" mark="Top"]
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E k g [link memo="Top" mark="Top"]
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P R O C E D U R E S [link memo="Top" mark="Top"]
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........................
.......d8888............
......d88888............
.....d88P888............
....d88P.888............
...d88P..888............
..d88P...888............
.d8888888888............
d88P.....888.ssessment..


Patient is a [select name="variable_01" value=""] year old [select name="variable_02" value=""] hospital day [select name="variable_29" value=""] [select name="variable_17" value=""] [select name="variable_03" value=""] with a past medical history significant for [checkbox name="variable_18" value=""].

[textarea default=""]

...............
..8888888b.....
..888...Y88b...
..888....888...
..888...d88P...
..8888888P"....
..888 .........
..888..........
..888.lan......

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#A C T I V E [link memo="Top" mark="Top"]
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#[text default=""]
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$C H R O N I C [link memo="Top" mark="Top"]
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$[text default=""]
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$[text default=""]
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R E S O L V E D [link memo="Top" mark="Top"]
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O T H E R [link memo="Top" mark="Top"]
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#Consults [link memo="Top" mark="Top"]
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F A S T . H U G S . B I D . D / C [link memo="Top" mark="Top"]
.................................
 
F - Food
- [text default="Renal Diet/Na Controlled"]

A - Analgesia
- [text default="Acetaminophen"]

S - Sedation
- [text default="None"]

T - ThromboPPx
- [text default="Heparin"]

H - Head of Bed Elevation 
- [text default="Yes"]

U - Ulcer PPx
- [text default="Pantoprazole @@@"]

G - Glycemic Control
- [text default="Goal 140-180 @@@"]
- [text default="Meds: None Required"]

S - Spontaneous Breathing Trial
- [text default="None Required @@@"]

B - Bowel Reg
- [text default="None Required @@@"]

I - IV+Lines/Drains/Catheter
- [text default="
- IV+Lines: 1x Peripheral IV
- Drains: None
- Catheter: Condom"]

D - De-escalating Antibiotic(s)
- [text default="None Required @@@"]

D - Dispo
- [text default="stable @@@"]

C - Code Status
- [text default="Full @@@"]

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C O N T A C T S
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[textarea default=""]

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S I G N A T U R E
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[textarea default="
I am under supervision of attending @@@@.

CAPT. Drew (Andrew) J. La'Pelusa Staples, MD, MS
USARMY, MC
CDU IM PGY1"]




[shorthand name="#AKI" value="
#AKI 
-Creatinine up to 1.64 today 
-ATN vs. pre-renal vs. pulmonary renal syndrome
- Will place foley
- Order urine lytes, eos
- Renal US
- Nephrology consult"]


[shorthand name="#CAD3"]
#CAD - extensive, 3 vessel, hx of STEMI x2 (2002, 2017) s/p AICD placement
-Per cardiology, poor candidate for stenting and CABG
- Continue heparin gtt
- Continue aspirin \
[/shorthand]



[shorthand name=".#cardiogenic shock"]
#Cardiogenic shock
- Continue milrinone per cardiology recs
- Trend lactates
- Cardiology following
- Unclear endpoint for milrinone titration - will discuss with cardiology
[/shorthand]



[shorthand name="#ESRD"]
#ESRD on HD, currently undergoing HD daily for volume overload
- Next HD session tomorrow
[/shorthand]



[shorthand name="#nutrition"]
[/shorthand]


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[mark name="calculate"] [link memo="Top" mark="Top"]
                                               

Note - this form uses SOAPnote Shorthand. For a table of all phrases click View > Data Dictionary






Top

Top


ID
. Updates
. tele

S
. ros

O
. Vitals
. physical exam
. I&O
. Labs

calculate


ID Top
..................
I D
..................

Name:
Age:
Date of Admission:
Initial Chief Complaint:
# CHIEF COMPLAINT: #

Admission Diagnosis:
ICU Day:
ICU Diagnosis:
PMH:


updates Top


Patient is a year old hospital day with a relevant past medical history significant for .

Other significant but non-pertinent past medical history includes:

..................
U P D A T E S
..................


tele Top
1.Check Tele

Any Events? Any VT?

What was the event? VT? AFib?

When?
Date
Name
Results



For How Long


Was Pt. Symptommatic?


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d88P..Y88b........................................
Y88b..............................................
."Y888b...........................................
...."Y88b.........................................
......"888........................................
Y88b..d88P........................................
."Y8888P"..ubjective .............................
..................................................
subjective Top




# Patient states that they were was in their usual state of health until ""

# Patient seen and examined this morning.

# Patient .

# Patient .

# Patient .

# Patient is currently is *** in pain**"" and rated a "" out of 10.
- The pain is described as " dull "
- The pain is described as " sharp "
- The pain is described as " crampy "
- The pain is described as " an ache "
- The pain is described as " X "


ros Top
.....................
R O S
.....................





Constitutional


Eyes


Ears, Nose, & Throat


Cardiovascular


Gastrointestinal


Genitourinary


Musculoskeletal


Immunologic


Endocrinology


Dermatological


Neurological


Psychiatric



objective Top
..d88888b.........................................
d88P" "Y88b.......................................
888.....888.......................................
888.....888.......................................
888.....888.......................................
888.....888.......................................
Y88b...d88P.......................................
."Y88888P"..bjective..............................


vitals Top
.....................
V i t a l s
.....................


T \\
HR \\
BP \\
P \\
RR \\
O2 \\



Top physical exam

.....................
P . E
.....................

Gen:

HEENT:




Neck:


Heart:




Pulm:



Abd:






Exts: No edema
No clubbing


Neuro: A&Ox4
normal speech
motor grossly intact
sensory grossly intact





TopI&O
.....................
I & O
.....................

I mL
O mL
T mL
UOP mL

Toplabs
.....................
L A B S Top
.....................

C B C Top


Wbc \\



Rbc \\



Hgb \\



Plt \\


C H E M Top


Na \\


K \\

Ca \\

Co2 \\

Cl \\

Mg \\

PO \\

AG \\

BUN \\

Cr \\

GFR \\

Glu \\

A1c \\

PT \\

PTT \\

INR \\

DD \\

Lac \\

L F T

AST \\

ALT \\

ALK \\

DB \\

IDB \\

TB \\

Alb \\

Prot \\

AMMONIA \\

\\

\\

\\

BLOOD GAS

PH \\


PCO2 \\

PO2 \\

HCO3 \\

OXHGB \\

CBXYHGB \\

METGB //

.....................
M i c r o Top
.....................

Date
Name
Results


Date
Name
Results


Date
Name
Results


Date
Name
Results



.....................
I M A G I N G Top
.....................

.....................
X r a y Top
.....................

Date
Name
Results



Date
Name
Results



Date
Name
Results



.....................
C t Top
.....................

Date
Name
Results



Date
Name
Results



Date
Name
Results



.....................
E c h o / U s Top
.....................

Date
Name
Results


Date
Name
Results


Date
Name
Results


.....................
E k g Top
.....................

Date
Results


Date
Results


Date
Results




.....................
P R O C E D U R E S Top
.....................


Date
Name
Results


Date
Name
Results


Date
Name
Results



Top
........................
.......d8888............
......d88888............
.....d88P888............
....d88P.888............
...d88P..888............
..d88P...888............
.d8888888888............
d88P.....888.ssessment..


Patient is a year old hospital day with a past medical history significant for .



...............
..8888888b.....
..888...Y88b...
..888....888...
..888...d88P...
..8888888P"....
..888 .........
..888..........
..888.lan......

.....................
#A C T I V E Top
.....................

#

-
-
-

#

-
-
-

#

-
-
-

.....................
$C H R O N I C Top
.....................

$

-
-
-

$

-
-
-

$

-
-
-

.....................
R E S O L V E D Top
.....................

#

-
-
-

#

-
-
-

#

-
-
-

.....................
O T H E R Top
.....................

#Consults Top
-
-
-
-
-
-

.................................
F A S T . H U G S . B I D . D / C Top
.................................

F - Food
-

A - Analgesia
-

S - Sedation
-

T - ThromboPPx
-

H - Head of Bed Elevation
-

U - Ulcer PPx
-

G - Glycemic Control
-
-

S - Spontaneous Breathing Trial
-

B - Bowel Reg
-

I - IV+Lines/Drains/Catheter
-

D - De-escalating Antibiotic(s)
-

D - Dispo
-

C - Code Status
-

.....................
C O N T A C T S
.....................



.....................
S I G N A T U R E
.....................


































calculate Top

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