Complete Note
Loading Add to Favorites
Share
Tweet
Cite
[comment memo="For use on FMIT Service"]
[comment memo="Inpatient Progress Note SO Portion"]
[text size="3"]yo [select name="AD1" value="active duty|retired|dependent"] [conditional field="AD1" condition="(AD1).isNot('dependent')"][text default="rank" size="6"] [/conditional][select value="M|F"] admitted for [text size="80"], hospital day [select value="1|2|3|4|5|6|7|8|9"].

Overnight/24hr events/changes: [textarea default="unremarkable"]

Additional/new patient concerns: [textarea default="no patient concerns at this time"]

PE: [comment memo="Use freetext for pertinent PE abnormals"]
Vitals- [select name="Vitals" value="reviewed/stable|reviewed/pertinent for- "][conditional field="Vitals" condition="(Vitals).is('reviewed/pertinent for- ')"][text default="BP *, HR *, RR *, T *, SpO2 * % on *L" size="60"][/conditional]
GEN- [text size="60"] [checkbox value="well developed|well nourished|A&Ox4|NAD"]
HEENT- [text size="60"] [checkbox value="Normocephalic|atraumatic|conjunctiva clear|sclerae aninteric|TMs with clearly visible landmarks|nares patent|mucous membranes moist|throat nonerythematous/noninjected|good dentition"]
Neck- [text size="60"] [checkbox value="soft/supple|no JVD|no thyromegaly|no tender/enlarged lymph nodes"]
CHEST- [text size="60"] [checkbox value="Normal rise and fall B/L|No accessory muscle use"]
HEART- [text size="60"] [checkbox value="RRR|normal S1/S2|No M/R/G|No S3/S4 auscultated|no friction rub"]
LUNGS- [text size="60"] [checkbox value="CTAB|BSE b/l|no wheezes|no crackles|no rhonchi"]
ABD- [text size="60"] [checkbox value="soft|nontender|nondistended|no voluntary/involuntary guarding|no peritoneal signs|bowel sounds present in all 4 quadrants"]
SKIN- [text size="60"] [checkbox value="warm|dry|intact|no edema|no erythema|no ecchymosis"]
EXT- [text size="60"] [checkbox value="no gross deformities noted|no cyanosis|no clubbing"]
NEURO- [text size="60"] [checkbox value="mentating well|moves all extremities equally well|CN 2-12 grossly intact b/l|normal sensorium all 4 extremities|no gross motor deficits|Romberg negative|cerebellar testing normal|DTRs 2/4 x4|gait testing without abnormalities"]

Labs- [select name="Labs" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Labs" condition="(Labs).is('reviewed/notable for- ')"][textarea][/conditional]

Rads- [select name="Rads" value="nothing to review|reviewed/unremarkable|reviewed/notable for- "][conditional field="Rads" condition="(Rads).is('reviewed/notable for- ')"][textarea][/conditional]

__________________________________________________________
[comment memo="Inpatient Progress Note AP Section"]
A/P: [text size="3"]yo [select name="AD2" value="active duty|retired|dependent"] [conditional field="AD2" condition="(AD2).isNot('dependent')"][text default="rank" size="6"] [/conditional][select value="M|F"] admitted for [text size="80"], hospital day [select value="1|2|3|4|5|6|7|8|9"], clinical status [select value="improving|stable|declining"].

#[textarea default="dx - discussion/plan" cols="100" rows="6"]

[select name="Problem1" value="|#"][conditional field="Problem1" condition="(Problem1).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem2" value="|#"][conditional field="Problem2" condition="(Problem2).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem3" value="|#"][conditional field="Problem3" condition="(Problem3).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem4" value="|#"][conditional field="Problem4" condition="(Problem4).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"]

[/conditional][select name="Problem5" value="|#"][comment memo="Drop-downs for add'l problems"][conditional field="Problem5" condition="(Problem5).is('#')"][textarea default="dx - discussion/plan" cols="100" rows="6"][/conditional]

Chronic Medical Conditions: [select name="Chronic" value="none|as follows"]
[conditional field="Chronic" condition="(Chronic).is('as follows')"][textarea default="#dx - stable. no issues. continue current home treatment/meds." cols="80" rows="10"]

[/conditional]
Prophylaxis
GI- [select value="not indicated|PPI"]
DVT- [select value="low padua score|SCDs|Lovenox|Heparin"]

Dispo: Anticipate discharge home once [comment memo="List discharge criteria"][checkbox value="tolerating PO|dehydration resolved|stable O2 requirement|no O2 requirement|off of IV antibiotics|no longer requiring IV narcotics for pain control|pain adequately resolving"][text size="80"].

Code status: [select value="Full Code|DNR/DNI"]

[textarea default="signature block" cols="50" rows="3"]
[comment memo="For use on FMIT Service"]
For use on FMIT Service
Inpatient Progress Note SO Portion
yo admitted for , hospital day .

Overnight/24hr events/changes:

Additional/new patient concerns:

PE: Use freetext for pertinent PE abnormals
Vitals-
GEN-
HEENT-
Neck-
CHEST-
HEART-
LUNGS-
ABD-
SKIN-
EXT-
NEURO-

Labs-

Rads-

__________________________________________________________
Inpatient Progress Note AP Section
A/P: yo admitted for , hospital day , clinical status .

#

Drop-downs for add'l problems

Chronic Medical Conditions:

Prophylaxis
GI-
DVT-

Dispo: Anticipate discharge home once List discharge criteria .

Code status:


For use on FMIT Service
Result - Copy and paste this output: