Inpatient Progress Note (OFFICIAL, 4/28)

[comment memo=Font:Tahoma,Size:11]
Name: [text name="variable_1" default="Doe, Jane"]
DOB: [date name="variable_2" default="04-26-2023"]
Gender: [select name="variable_3" value="Female|Male|Other"]
Code Status:[select name="variable_4" value="Full Code|DNR + CCA|DNR + CCC"]
--------FOR ID PURPOSES ONLY--------

SUBJECTIVE
CC: [textarea name="variable_5" default="(1 PHRASE) shortness of breath x4 days. "]

Last 24 HR:
[textarea name="variable_6" default="Summarize updates from last 24 hr. Ex: 1. GI performed X, found..."]
     
[comment memo="Overnight Events:"]
[textarea name="variable_8" default="PT had no acute events overnight."]
[comment memo="Last 2-3 Hrs:"]
[textarea name="variable_9" default=" PT was seen and examined at bedside this AM or PM. PT states:... Discussed..."]
Last bowel movement: [text name="variable_500" default="date, time, stool bristol cat."]

Review of Systems 
Constitutional: [checklist name="variable_13" value="fever|chills|fatigue|appetite changes"] HEENT: [checklist name="variable_14" value= "headaches|problems with vision|problems with hearing|trouble swallowing"]Resp: [checklist name="variable_15" value="SOB|cough"]Cardio: [checklist name="variable_16" value="chest pain|palpitations"]GI: [checklist name="variable_17" value="nausea|vomiting|diarrhea|constipation|abdominal pain|rectal bleeding"]GU: [checklist name="variable_18" value="difficulty peeing|urgency|flank pain"]MSK: [checklist name="variable_19" value="changes in pain level|changes in ROM|difficulty walking"]Peripheral Vasc: [checklist name="variable_20" value="UE swelling|LE swelling|cramping"]Skin: [checklist name="variable_21" value="rashes|other skin complaints"]Neurologic: [checklist name="variable_22" value="headaches|seizures|LOC|paralysis|loss of balance"]Endocrine: [checklist name="variable_23" value="change in thirst|change in appetite"]Psych: [checklist name="variable_24" value="anxiety|depression|sleep issues|changes in mood"]
[comment memo=" Medication list in Subjective if DR starting from scratch. Existing med list that has been verified with PT is found in Objective "]
Medications
Total Active: [calc value="score1=(variable_64)+(variable_66)+(variable(68)"]
Scheduled ([text name="variable_64" default="#"])
[textarea name="variable_65" default="drug A, tab/patch/cap #mg = topical/oral, daily/evening/weekly."]
Continuous([text name="variable_66" default="#"])
[textarea name="variable_67" default="drug A, tab/patch/cap #mg = topical/oral, daily/evening/weekly."]
PRN([text name="variable_68" default="#"])
[textarea name="variable_69" default="drug A, tab/patch/cap #mg = topical/oral, daily/evening/weekly."]


OBJECTIVE 

Vitals & Measurements
T:[text name="variable_25" default=""] Tmin:[text name="variable_27" default=""] Tmax:[text name="variable_26" default=""] HR:[text name="variable_28" default=""] RR:[text name="variable_29" default=""] BP:[text name="variable_37" default=""] MAP:[text name="variable_30" default=""] SPO2:[text name="variable_31" default=""] HT:[text name="variable_32" default=""] WT:[text name="variable_33" default=""] BMI:[text name="variable_34" default=""] 

Physical Exam
General:[select name="variable_1" value="Well nourished, alert & cooperative, in no acute distress.|ABNORMAL"]
Neuro:[select name="variable_1" value="Alert & oriented X4; CN II-XII intact. Strength and sensation symmetric and intact throughout. Reflexes 2+ throughout.|ABNORMAL"]
HEENT: [select name="variable_1" value="Normocephalic, Normal Vision, Normal hearing, nasal and mucosa are pink and moist|ABNORMAL"]
Neck: [select name="variable_1" value="Supple, nontender w/o lymphadenopathy or masses, midline trachea with no JVD|ABNORMAL"]
Cardio: [select name="variable_45" value="Normal rate, regular rhythm, no murmur, no peripheral edema or cyanosis, pulses equal in all extremities|ABNORMAL"]
Respiratory:[select name="variable_46" value="Clear to auscultation, no rales, rhonchi, wheezing or diminished breath sounds B/L. |ABNORMAL"]
GI: [select name="variable_47" value="Soft, nondistended and nontender. No guarding or rebound, normal bowel sounds.|ABNORMAL"]
Integumentary: [select name="variable_49" value="Normal color, texture and turgor, no lesions or eruptions.|ABNORMAL"]
MSK: [select name="variable_51" value=":Normal ROM, no deformities|ABNORMAL"]
Psych:[select name="variable_55" value="Cooperative, appropriate mood and affect|ABNORMAL"]

Lab results: 
[textarea name="variable_70" default=""]
Diagnostic results: 
[textarea name="variable_71" default=""]

ASSESSMENT/PLAN
[comment memo="Summary of PT (1 sentence)."]
[textarea name="variable_400" default="# yo M/F with PMHx ___ presents to __ with cc ___. Was admitted to ___ for _____."]
Level of care: [textarea name="variable_401" default="Ex: Med/surg under observation status OR Telemetry under observation status."]



#[comment memo="Problem 1"][text name="variable_73" default=""]
 Plan: [textarea name="variable_74" default="Chronology of what has been done to address problem, highlight ongoing"]

#[comment memo="Problem 1"][text name="variable_75" default=""]
 Plan: [textarea name="variable_76" default=""]

#[comment memo="Problem 3"][text name="variable_77" default=""]
 Plan: [textarea name="variable_78" default=""]
 
 Disposition: [select name="variable_200" value="I believe that PT will require hospitalization stay less than 48 hours. PT will likely be discharged home|I believe that PT will require hospitalization stay greater than 48 hours. PT will likely be discharged home| Add more as you find"]
 
 Diet: [select name="variable_79" value="NPO: NPO except for medications|Add more as you find them"] [text name="variable_80" default="DATE"][text name="variable_81" default="TIME"][text name="variable_82" default="DR NAME who made order"]
 
 [select name="variable_83" value="NONE|DVT|GI|Add more as you find"]Prophylaxis
 [text name="variable_84" default="DRUG"][text name="variable_85" default="DATE"][text name="variable_86" default="TIME"][text name="variable_87" default="DR NAME who made order"
  [select name="variable_88" value="NONE|DVT|GI|Add more as you find"]Prophylaxis
 [text name="variable_89" default="DRUG"][text name="variable_90" default="DATE"][text name="variable_91" default="TIME"][text name="variable_92" default="DR NAME who made order"]
 [textarea name="variable_1" default="No current orders found."]
 
Hospital Course
[textarea name="variable_93" default="Chronologic summary of what has happened in hospital. (D0, month/day) PT arrived to ED via ..."]
 
Authenticated by: [text name="variable_94" default="DR NAME"] on [text name="variable_90" default="DATE"][text name="variable_91" default="TIME"]
Electronically Signed by:  [text name="variable_94" default="DR NAME"] on [text name="variable_90" default="DATE"][text name="variable_91" default="TIME"]
Performed by:  [text name="variable_94" default="DR NAME"]