Hospital Discharge

ED COURSE:
Upon arrival to the emergency department, 

Patient presented with [text default="a #___ hour/ day duration of" size=30]
[checkbox value="abdominal pain|altered mental status|chest pain|dyspnea|shortness of breath|dysuria|fever|nausea|vomiting|dysuria"] [text size= 75] 

In the ED, patient was found to be [comment memo=”...“ memo_color="black"]
[checkbox value="hypertensive|hypotensive|normotensive|tachycardic|bradycardic|tachypnic|febrile|afebrile|hypoxic"][text size= 50]
[comment memo=”...“ memo_color="black"]  for which [comment memo=”...“ memo_color="black"]

[checkbox value="IV fluid bolus|antipyretics|loading dose of ASA|supplemental O2"] 
[text size= 75]

[comment memo=”...“ memo_color="black"]  was/ were provided. 

[mark memo="ER Diagnostic Workup:" name="mark"]
[checkbox value="All labs done in the ER were unremarkable|Troponin levels were WNL|D-Dimer levels were < 500"]
[checkbox value="EKG results were unremarkable|UA results indicated urinary tract infection unlikely"]
[checkbox name="variable_1" value="All imaging performed in the ER were unremarkable|CXR was unremarkable|CTA-PE ruled out a potential presence of a PE"]
[textarea name="variable_1" default="Additional ER course documentation"]

After a thorough evaluation, the ER consulted the on-call family medicine residents and the decision to admit the patient to the hospital was determined. 

[comment memo=”******************************************************“ memo_color="black"]

[comment memo="Next section is dedicated to communicating the story associated with the patient’s hospitalization" memo_color="blue" memo_style="bold" memo_size="small"]
\ * [comment memo="How did the patient present?" memo_color="blue" memo_style="bold-italic" memo_size="small"]
\ * [comment memo="What was the key hx that provided clues to the diagnosis and severity of presentation? " memo_color="blue" memo_style="bold" memo_size="small"]
\ * [comment memo="Were there any events that affected management during the course of hospitalization?" memo_color="blue" memo_style="bold" memo_size="small"]


[comment memo=”******************************************************“ memo_color="black"]


HOSPITAL COURSE: 

Patient was admitted to (the) [select value="|ICU|medical floor|inpatient rehab|LTAC"]
[comment memo=”...“ memo_color="black"]  for  [comment memo=”...“ memo_color="black"]
[checkbox value="ACS rule out|AMS|asthma exacerbation|CHF exacerbation|COPD exacerbation|chest pain|complicated UTI|COPD exacerbation|COVID infection"][checkbox value="sepsis likely secondary to"][text size=30][checkbox value="septic shock likely secondary to"][text size=30][checkbox value="shortness of breath|vomiting"][textarea] 

[comment memo=”...“ memo_color="black"] that required initiation/administration of  [comment memo=”...“ memo_color="black"]
[checkbox value="antibiotics regiment that included"] [text size=25] [checkbox value="blood transfusion"] [text size=25 default"units"] [checkbox value="bolus of IV fluids|intubation|maintenance IV fluids|vasopressors"][textarea] 

[comment memo="Alternative Opening Descriptions:" memo_style="bold"]
[textarea fillable="true" default="A preliminary diagnosis of ****** was established.\n\tOther causes of ****** were possible but less likely.\n\nEtiology is not known.\n\tPotential causes considered include:****** ."]

[comment memo="List of Problems" memo_style=bold]
[checkbox value="ACUTE CYSTITIS: |ASTHMA: |ACUTE HYPOXIC RESPIRATORY FAILURE: |ACUTE KIDNEY INJURY: |CELLULITIS: |ACUTE CHOLELITHIASIS: |COVID PNEUMONIA: |PNEUMONIA: |PYELONEPHRITIS: |RHABDOMYOLYSIS: | TRANSIENT ISCHEMIC ATTACK: |URINARY TRACT INFECTION, COMPLICATED:"][text size=50].

Current Status: 
[checkbox value="Resolved|Improved|Improving|Worsened|Worsening"] [text size=30].

On admission, patient was found to be [comment memo=”...“ memo_color="black"]
[checkbox value="afebrile|febrile|normotensive|hypertensive|hypotensive|tachycardic|bradycardic|tachypnic|hypoxic"] [text size=50].

[comment memo=”...“ memo_color="black"] on initial assessment with a [comment memo=”...“ memo_color="black"] 
[checkbox value="blood pressure of"] [text default="___ / ___" size=30].
[checkbox value="heart rate of"] [text default="___ bpm" size=30].
[checkbox value="respiratory rate of"] [text default="___ /min" size=30].
[checkbox value="temperature of"] [text default="___ ℉" size=30].
[checkbox value="O2 saturation of"] [text default="on RA / #___ L of O2 via NC" size=50].

Patient was also started on…  [comment memo=”...“ memo_color="black"] 
[checkbox value="antibiotics|aspirin 81 mg|β-blockers|ACEi / ARB|high-intensity statin|heparin"] [text size=75].

[comment memo="Other Management:"]
[checkbox value="Administered NS 0.9%"][text default="#___ L IV fluid bolus to correct hypotension" size=50][checkbox value="Started on aggressive IV fluid management.|Arterial line was inserted for hemodynamic monitoring.|CIWA protocol was initiated due to history of EtOH abuse."][checkbox value="Hemodynamics were supported with"][text size=50].[checkbox value="Wound care was requested"][textarea]

[comment memo="For the next section, consider only info that would be important to the PCP seeing pt at f/up" memo_size="large" memo_color="green" memo_style="bold"]

[mark memo_color="red" memo_style="italic" memo="ONLY include lab, micro, procedure, and imaging findings, following admin to the hospital that is RELEVANT to future decision-making healthcare"]

[comment memo_style="bold" memo_color="yellow" memo="Lab Results"]
Labs were done. 

[comment memo_color="black" memo_style="bold" memo="Complete Blood Count (CBC)"]

[checkbox value="WBC"] [textarea rows=1 cols=50 fillable="true" default="with ****** predominance"]
[checkbox value="H/H"] [text size=50]
[checkbox value="MCV"] [text size=50]
[checkbox value="Platelets"] [text size=50]

[comment memo_color="black" memo_style="bold" memo="Comprehensive Metabolic Panel (CMP)"]

[checkbox value="Na+"] [text size=50]
[checkbox value="K+"] [text size=50]
[checkbox value="Ca+"] [text size=50]
[checkbox value="BUN"] [text size=50]
[checkbox value="Cr"] [text size=50]
[checkbox value="AST"] [text size=50]
[checkbox value="ALT"] [text size=50]
[checkbox value="Albumin"] [text size=50]

[comment memo_color="black" memo_style="bold" memo="Other Metabolic Labs"]

[checkbox value="HbA1c"] [text size=50]
[checkbox value="Triglycerides"] [text size=50]
[checkbox value="HDL"] [text size=50]
[checkbox value="LDL"] [text size=50]
[checkbox value="TSH"] [text size=50]
[checkbox value="Lipase"] [text size=50]
[checkbox value="Amylase"] [text size=50]

[comment memo_color="black" memo_style="bold" memo="Cardiac/Inflammatory Labs"]

[checkbox value="BNP"] [text size=50]

[checkbox value="Troponin (trend):"] [textarea fillable="true" rows=1 cols=50 default="****** → ****** → ******"] 

[checkbox value="CK (trend):"] [textarea fillable="true" rows=1 cols=50 default="****** → ****** → ******"]

[checkbox value="Elevated inflammatory markers."] [textarea cols=50 row=1 default="***CRP & Procalcitonin***"]

[checkbox value="Serum lactate"] [textarea fillable="true" rows=1 cols=50 default="****** which returned to normal on reflex."]

[comment memo_color="black" memo_style="bold" memo="Other Labs "]

[checkbox value="ABG:"] [textarea fillable="true" rows=1 cols=50 default="pH ******, pCO2 ******, HCO3 ******"] 

[textarea rows=3 cols=50]

[comment memo_color="black" memo_style="bold" memo="Labs Result Discussion"]
[textarea rows=5 cols=75 default="These findings were thought to be likely related to/ caused by...
\n\tend organ hypoperfusion in the setting of sepsis
\n\nThese findings indicated...
\n\tend organ hypoperfusion in the setting of sepsis"]

[comment memo_color="black" memo_style="bold" memo="Updates following Labs Results"]

[checkbox value="Serial CIP’s & EKGs were ordered"][checkbox value="Received FFP"][checkbox value="Received Factor X"][checkbox value="Started on BiPap"]
[checkbox value="Administered K-Dur 40 MEQ"] [textarea fillable="true" rows=2 cols=50 default="x ****** doses to correct hypokalemia. \n\tK+ levels returned to normal at discharge"]

[checkbox value="Patient required High Flow Nasal Therapy (HFNT) via Airvo"] [text size=50 default="for new onset respiratory failure."]

[checkbox value="Received blood transfusion"] [textarea fillable="true" rows=2 cols=50 default="for a total of ****** units of blood. \n\tHemoglobin levels rose to ***>7***."]

[textarea cols=50 rows=3]

[comment memo_style="bold" memo_color="yellow" memo="Collected Cultures"]

[checkbox value="blood cultures (x2)|sputum cultures|wound cultures|urine cultures"] [text size=50]

[comment memo_style=bold memo_color= yellow memo="Microbiology Discussion & Updates"]

[checkbox value="were positive for"][textarea fillable="true" rows=2 cols=50 default="****** that were sensitive to ******"]

[checkbox value="Due to the results of the culture & sensitivities, antibiotic were switched to"][text size=50 rows=1]

[checkbox value="were negative."][textarea fillable="true" rows=2 cols=50 default="No organisms were isolated after ****** hours of incubation."]

[textarea cols=50 rows=2]

[comment memo_style="bold" memo_color="yellow" memo="Ancillary Test Results"]
[comment memo_color=yellow memo_style=bold memo="Radiology / Imaging Results"]

[checkbox value="Chest XR"] [text size=50 default="indicated/showed/revealed "]

[checkbox value="Abdominal XR (KUB)"] [text size=50 default="indicated/showed/revealed"]

[textarea fillable="true" rows=3 cols=50  default="***XR*** showed ******.  \n***XR*** showed ******. \n***XR*** showed ******."]  

[checkbox value="CT Head w/o Contrast"][text size=50 default="indicated/showed/revealed "]

[checkbox value="CT Abd/ Pelvis"][text size=50 default="indicated/showed/revealed "]

[textarea fillable="true" rows=3 cols=50  default="***CT/MRI*** showed ******.  \n***CT/MRI*** showed ******. \n***CT/MRI*** showed ******."]  

[checkbox value="Lower Extremity US"][select value="negative|positive"] for a DVT. 

[checkbox value="CTA-PE"][select value="negative|positive"] for a PE. 

[checkbox value="Transthoracic Echocardiogram (TTE)"] [textarea fillable="true" rows=1 cols=50 default="EF was ***%***."] 

[textarea cols=50]
 
[comment memo_color=yellow memo_style=bold memo="Updates following Radiology / Imaging Findings"]

[checkbox value="IV maintenance fluids were discontinued"] [text size=50 default="due to fluid overload"]

[checkbox value="Lasix was started."]
[textarea cols=50 rows=2]

[comment memo_color=yellow memo_style=bold memo="Specialist Consultation"]
[checkbox value="Cardiology|Infectious Disease|Nephrology|Neurology|Pulmonology|Surgery"]
[textarea rows=2 cols=50]

[comment memo=”...“ memo_color="black"] was consulted given severity of symptoms on presentation.

[textarea cols=50 default="They recommended"]
[comment memo_color=yellow memo_style=bold memo="Interim Status:"]
[checkbox value="Patient was transferred to the medical floor in stable condition for continued monitoring."]

[comment memo_color=yellow memo_style=bold memo="Final Status:"]
[checkbox value="Patient’s was discharged in stable condition.|Vital signs returned to baseline at the time of discharge.|Hemodynamics stabilized.Responded well to fluid resuscitation"]
[checkbox value="Patient’s symptoms improved/resolved"]  [textarea fillable="true" rows=1 cols=50 default="after ****** hrs/ days."]

[checkbox value="Lab values improved/normalized"] [textarea fillable="true" rows=1 cols=50 default="after ****** hrs/ days with ******."]

[checkbox value="Requires assistance w/ ADLs|Sent home with O2 supplementation."]
[checkbox value="Started patient on a new medication to be taken at home.|Patient to continue on antibiotics at home."]
[checkbox value="Recommended patient f/up with their PCP in 1-2 weeks following discharge.|Instructed pt to return to the ED if they develop fever, CP, worsening SOB, or LOC/ fainting."]
[textarea rows=3 cols=50]

[checkbox value="Urinalysis"] [text size=50]
[checkbox value="EKG"] [text size=50]

[comment memo_color=yellow memo_style=bold memo="Updates following Ancillary Test Results:"]

[checkbox value="Serial CIP’s & EKGs were ordered"]
[textarea cols=50 rows=2]
[comment memo_color=yellow memo_style=bold memo="Radiology / Imaging Results"]

[checkbox value="Chest XR"] [text size=50 default="indicated/showed/revealed "]

[checkbox value="Abdominal XR (KUB)"] [text size=50 default="indicated/showed/revealed"]

[textarea fillable="true" rows=3 cols=50  default="***XR*** showed ******.  \n***XR*** showed ******. \n***XR*** showed ******."]  

[checkbox value="CT Head w/o Contrast"][text size=50 default="indicated/showed/revealed "]

[checkbox value="CT Abd/ Pelvis"][text size=50 default="indicated/showed/revealed "]

[textarea fillable="true" rows=3 cols=50  default="***CT/MRI*** showed ******.  \n***CT/MRI*** showed ******. \n***CT/MRI*** showed ******."]  

[checkbox value="Lower Extremity US"][select value="negative|positive"] for a DVT. 

[checkbox value="CTA-PE"][select value="negative|positive"] for a PE. 

[checkbox value="Transthoracic Echocardiogram (TTE)"] [textarea fillable="true" rows=1 cols=50 default="EF was ***%***."] 

[textarea cols=50]
 
[comment memo_color=yellow memo_style=bold memo="Updates following Radiology / Imaging Findings"]

[checkbox value="IV maintenance fluids were discontinued"] [text size=50 default="due to fluid overload"]

[checkbox value="Lasix was started."]
[textarea cols=50 rows=2]

[comment memo_color=yellow memo_style=bold memo="Specialist Consultation"]
[checkbox value="Cardiology|Infectious Disease|Nephrology|Neurology|Pulmonology|Surgery"]
[textarea rows=2 cols=50]

[comment memo=”...“ memo_color="black"] was consulted given severity of symptoms on presentation.

[textarea cols=50 default="They recommended"]
[comment memo_color=yellow memo_style=bold memo="Interim Status:"]
[checkbox value="Patient was transferred to the medical floor in stable condition for continued monitoring."]

[comment memo_color=yellow memo_style=bold memo="Final Status:"]
[checkbox value="Patient’s was discharged in stable condition.|Vital signs returned to baseline at the time of discharge.|Hemodynamics stabilized.Responded well to fluid resuscitation"]
[checkbox value="Patient’s symptoms improved/resolved"]  [textarea fillable="true" rows=1 cols=50 default="after ****** hrs/ days."]

[checkbox value="Lab values improved/normalized"] [textarea fillable="true" rows=1 cols=50 default="after ****** hrs/ days with ******."]

[checkbox value="Requires assistance w/ ADLs|Sent home with O2 supplementation."]
[checkbox value="Started patient on a new medication to be taken at home.|Patient to continue on antibiotics at home."]
[checkbox value="Recommended patient f/up with their PCP in 1-2 weeks following discharge.|Instructed pt to return to the ED if they develop fever, CP, worsening SOB, or LOC/ fainting."]
[textarea rows=3 cols=50]