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Room Number: [text name="variable_1" default=""]
SUBJECTIVE: [comment memo="Age"][text name="variable_2" default=""]y/o[comment memo="Sex"][checkbox name="variable_3" value="Male |Female "]with a PMH of:[textarea name="variable_4" default=""]
HPI:
[comment memo="Two liner summary with where they presented and with what complaints."]
[textarea name="variable_47" default=""]
ED Course:
[comment memo="Labs, Radiology, Micro"]
[textarea name="variable_48" default=""]
[checkbox name="variable_26" value="-Pt exterminated and evaluated during multidisciplinary rounds with ICU team and Dr. Alnajjar Mahafzah. Chart reviewed: including labs, imaging, diagnostic workups, and consult notes. Assessment and plan created, discussed and planned by Dr. Alanajjar Mahafzhh. |Per nursing no acute overnight events |Per nursing acute overnight events (described below) |-Pt remains on mechanical ventilation "]
[textarea name="variable_5" default=""]
Intake and Output:
[textarea name="variable_70" default=""]
Respiratory:
[textarea name="variable_71" default=""]
[checkbox name="variable_6" value=" Date Arrived to: ED |Date Arrived to: Hospital "]
[text name="variable_7" default=""]
Since being in ICU:
[textarea name="variable_9" default=""]

Physical:
Vitals: Temp:[text name="variable_65" default=""] HR:[text name="variable_66" default=""] RR:[text name="variable_67" default=""] BP:[text name="variable_68" default=""]
General:[checkbox name="variable_10" value="Intubated on Mechanical Ventilator| Intubated via Endotracheal Tube| Ill Appearing| No outward distress| WDWN| Obese "][textarea name="variable_18" default=""]
HEENT:[checkbox name="variable_11" value="EOMI| MMM| Neck supple| Trachea midline"][textarea name="variable_19" default=""]
Cardiac:[checkbox name="variable_12" value="RRR| Tachycardia| Bradycardia| No Murmurs| No Rubs| No Gallops| Irregular Irregular Rhythm"][textarea name="variable_20" default=""]
Respiratory:[checkbox name="variable_13" value="CTAAF with equal breath sounds b/l| Diminished breath sounds b/l| Air entry equal bilaterally| Intubated on mechanical ventilation| No wheezing| No rales| No rhonchi| Coarse breath sounds"] SiO2%:[text name="variable_27" default=""]
[textarea name="variable_21" default=""]
Abdominal:[checkbox name="variable_14" value="To visual inspection no scars, rashes, or masses| To auscultation bowel sounds present in all four quadrants| To palpitation abd is soft with no tenderness to palpitation, no hepatosplenomegaly, no pulsitile masses| Negative Murphy's| Negative McBurney's tenderness| Negative Rovsing's| Negative Rebound tenderness| Negative CVA tenderness"][textarea name="variable_22" default=""]
Neurological:
[checkbox name="variable_1" value="CNII-XII intact| UE DTR 2/4| LE DTR 2/4 | UE sensation intact| LE sensation intact | Negative Rhomberg| Negative Babinski's| Negative Pronatator Drift| No cerebellar deficit noted"]
[textarea name="variable_45" default=""]
Musculoskeletal:
[checkbox name="variable_76" value="UE strength 5/5| LE strength 5/5"]
[textarea name="variable_46" default=""]
GU: Urine Color is [textarea name="variable_28" default=""]
[textarea name="variable_29" default=""]
Skin:[checkbox name="variable_15" value="Warm| Dry| Intact Skin| No rashes| No lesions"]
[textarea name="variable_23" default=""]
Extremities:[checkbox name="variable_16" value="Pules present b/l in UE| Pulses present b/l in LE| No clubbing| No cyanosis| No Peripheral Edema"]
[textarea name="variable_24" default=""]
Psych:[checkbox name="variable_17" value="Unable to assess |Cooperative |Normal Affect"]
[textarea name="variable_25" default=""]
[comment memo="Tests"]
[checkbox name="variable_31" value="Lab Results"]
Glucose:[text name="variable_32" default=""] Na:[text name="variable_33" default=""] K:[text name="variable_34" default=""]Cl:[text name="variable_35" default=""] CO2:[text name="variable_36" default=""] AGAP:[text name="variable_37" default=""] Ca:[text name="variable_38" default=""] BUN[text name="variable_39" default=""] Cre:[text name="variable_40" default=""] Alb:[text name="variable_41" default=""] WBC:[text name="variable_72" default=""] Hgb:[text name="variable_73" default=""] Hct:[text name="variable_74" default=""]
[checkbox name="variable_42" value="Radiology Results"]
[textarea name="variable_43" default=""]
Medications:
[textarea name="variable_75" default=""]

Assessment:
#
#
#
[textarea name="variable_64" default=""]
[checkbox name="variable_52" value="H/O"]
[textarea name="variable_58" default=""]
[checkbox name="variable_53" value="H/O"]
[textarea name="variable_59" default=""][checkbox name="variable_54" value="H/O"]
[textarea name="variable_60" default=""][checkbox name="variable_55" value="H/O"]
[textarea name="variable_61" default=""][checkbox name="variable_56" value="H/O"]
[textarea name="variable_52" default=""][checkbox name="variable_57" value="H/O"]
[textarea name="variable_63" default=""]
Plan:

[comment memo="PLAN FOR NEW ADMIT WITH A DRIP"]
[checkbox name="variable_51" value="
-ADMIT TO ICU
-C/W LEVOPHED GTT AS NEEDED WITH GOAL SBP > 90 MMHG
-C/W ABX
-HOME MEDS AS APPROPRIATE
-MONITOR LABS
-MONITOR CX FOR GROWTH
-STRICT NPO WITH ASPIRATION PRECAUTIONS
-PULM TOILET - HOB > 30, ORAL CARE, DUONEBS PRN
-PAIN MANAGEMENT PRN
-ANTIEMETICS PRN
-BOWEL CARE PRN
-ELECTROLYTE REPLACEMENT PRN
-ID FOLLOWING
-PULM FOLLOWING
-CARDS FOLLOWING
-RENAL FOLLOWING
-GI FOLLOWING
-SUPPORTIVE CARE
CODE STATUS: FULL CODE
GI PPX: PEPCID
VTE PPX: HEPARIN SUB-Q
DISPO: CONTINUE WITH ICU LEVEL OF CARE 2/2 REQUIREMENT FOR MECHANICAL VENTILATION AND MULTIPLE TITRATABLE MEDICATED GTTS; PATIENT HIGHLY COMPLEX AT RISK FOR RAPID DECLINE.
|-ADMIT TO ICU
-C/W MECHANICAL VENTILATION
-SBT/VENT WEANING PROTOCOL WHEN APPROPRIATE AND AS TOLERATED
-C/W PROPOFOL GTT AS NEEDED WITH RASS GOAL 0 TO -2
-C/W FENTANYL GTT AS NEEDED WITH RASS GOAL 0 TO -2
-DAILY SEDATION VACATION
-C/W LEVOPHED GTT AS NEEDED WITH GOAL SBP > 90 MMHG
-C/W ABX
-HOME MEDS AS APPROPRIATE
-MONITOR LABS
-MONITOR CX FOR GROWTH
-STRICT NPO WITH ASPIRATION PRECAUTIONS
-PULM TOILET - HOB > 30, ORAL CARE, DUONEBS PRN
-PAIN MANAGEMENT PRN
-ANTIEMETICS PRN
-BOWEL CARE PRN
-ELECTROLYTE REPLACEMENT PRN
-ID FOLLOWING
-PULM FOLLOWING
-CARDS FOLLOWING
-RENAL FOLLOWING
-GI FOLLOWING
-SUPPORTIVE CARE
CODE STATUS: FULL CODE
GI PPX: PEPCID
VTE PPX: HEPARIN SUB-Q
DISPO: CONTINUE WITH ICU LEVEL OF CARE 2/2 REQUIREMENT FOR MECHANICAL VENTILATION AND MULTIPLE TITRATABLE MEDICATED GTTS; PATIENT HIGHLY COMPLEX AT RISK FOR RAPID DECLINE."]
Room Number:
SUBJECTIVE: Agey/oSex with a PMH of:
HPI:
Two liner summary with where they presented and with what complaints.

ED Course:
Labs, Radiology, Micro



Intake and Output:

Respiratory:



Since being in ICU:


Physical:
Vitals: Temp: HR: RR: BP:
General:
HEENT:
Cardiac:
Respiratory: SiO2%:

Abdominal:
Neurological:


Musculoskeletal:


GU: Urine Color is

Skin:

Extremities:

Psych:

Tests

Glucose: Na: K:Cl: CO2: AGAP: Ca: BUN Cre: Alb: WBC: Hgb: Hct:


Medications:


Assessment:
#
#
#









Plan:

PLAN FOR NEW ADMIT WITH A DRIP

Result - Copy and paste this output:

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