Morning Rounds Presentation
[text name="tn1" default="Mr|Mrs|Ms"] [text name="tn2" default="name"] ([text name="tn3" default="pronouns"]) is a [text name="tn4" default="age"] year-old [text name="tn5" default="option A|option B|option C"] who [text name="tn6" default="POD #"] for [text name="tn7" default="reason for being here"] for [text name="tn8" default="indication"] Overnight, [text name="tn3" default="pronoun"] [text name="tnpertinent overnight events" default="pertinent overnight events (fever, pain, etc)"]. This morning [text name="tn2" default="name"] [text name="subjective exam: pain, fever, chills, nausea, vomiting, flatus, bowel movements, etc" default="subjective exam: pain, fever, chills, nausea, vomiting, flatus, bowel movements, etc"]  [Her/his] vitals are [Tmax, Tcurrent, HR, BP, RR, O2 %, oxygen delivery] (do not need to say prefix, just give numbers) [Her/his] 24-hour ins/outs are [24hr I/O], with a urine output [most recent 8hr shift, previous 8hr shift, 8hr shift before that] per shift, and [any other tubes/drains that patient has - NG tube, JP drain, etc], [blood products if applicable - packed RBC, cryo, FFP, platelets] On exam, [patient] is [general exam - doing well, in no acute distress], Heart is [cardiac findings], Lungs are [pulmonary findings], abdominal exam reveals [abdominal findings]. Incisions/dressing is [findings - clean, dry, and intact]. Ostomy is [color, patency, protuberant or not, productive or not]. Vascular exam reveals [vascular findings, if pertinent]. [Any other pertinent exam findings] [Labs drawn - CMP, CBC w/ differential, etc] for [indication] shows [lab findings]. [Imaging study performed] done for [indication] shows [findings]. (only necessary to report if these are new labs or imaging studies) In summary, [patient] is [age] year-old [f/m] post-op day [POD #] from [surgery] for [indication for surgery] who is [general assessment, ie improving, stable, developing shock, septic, etc.] Plan for today is (pertinent info only): • Neuro/psych/pain • Respiratory (also include incentive spirometry, pulmonary toilet) • Cardiac • GI • GU/renal • Heme (include DVT prophylaxis) • Infectious disease • Endocrine • MSK/activity • Other pertinent systems (derm, rheum, etc.) • Dispo (rehab, home, transfer to ICU, keep on floor, etc.)
There are 12 form elements.