ONGOING PATIENT Presentation – 4-Minute Limit

1. Opening Statement: This is *** whose primary ongoing problem is *****

2. Overnight Update - "Since yesterday, the following occurred"
a. Update on urgent events (RRT, Code, Transfer)
b. Update on new consultations
c. Update on new labs and diagnostic tests

3. Current Status - "This morning"
a. Update on how the patient feels
b. New patient concerns arising over night
c. Review of important physical findings
i. Vital signs including weight & changes in weight
ii. Fluid status including net fluid status today & over the hospital course 

iii. Physical Exam findings & changes RELEVANT to the problem list
d. Labs from today including point of care blood sugar testing
e. Procedure & Radiology results if not already reviewed


4. Assessment and Plan - By Problem
a. Ongoing Problem List - Keep a list & use it.
i. Key Factors & Problem Representation for ongoing and new problems
b. Problem List Adjustment as new problems occur or as some problems change relevance or status
c. Maintenance Issues in your problem list
i. Diet
ii. Fluid Orders, Current orders & volume status 
iii. Foley Catheter 
iv. Telemetry
v. Central Lines
vi. Activity Orders, BMAT, PT, OT & Compliance with activity orders 
vii. Skin Integrity 
viii. Bowel Status 
ix. DVT Prophylaxis
x. Adjustments required relevant to NPO, blood sugars, anticoagulation, preparation for procedures
d. Discharge Planning
i. Discharge location
ii. Medications & Medication Reconciliation including drug interactions 
iii. Outpatient Follow-up 
iv. DME & 02
v. Pending Issues

5. Life-long Learning
a. Competently address core question and identify a learning question for the day.

updated clinical assessment of status and severity for each problem. use guideline based diagnostic and evaluative criteria. integrate this pasted information into the assessment and plan. organize the assessment and plan by problem in order of severity and acuity. Each problem should have a clinical assessment of that problem's status and then orders and plan to address that problem. Use evidence based and guidelines for assessment. Ensure orders are evidence based and gold standard for each problem.. use the most updated information for each problem and include problems or abnormalities not addressed.

1. Opening Statement: This is *** whose primary ongoing problem is *****

2. Overnight Update - "Since yesterday, the following occurred"
a. Update on urgent events (RRT, Code, Transfer)
b. Update on new consultations
c. Update on new labs and diagnostic tests

3. Current Status - "This morning"
a. Update on how the patient feels
b. New patient concerns arising over night
c. Review of important physical findings
i. Vital signs including weight & changes in weight
ii. Fluid status including net fluid status today & over the hospital course

iii. Physical Exam findings & changes RELEVANT to the problem list
d. Labs from today including point of care blood sugar testing
e. Procedure & Radiology results if not already reviewed


4. Assessment and Plan - By Problem
a. Ongoing Problem List - Keep a list & use it.
i. Key Factors & Problem Representation for ongoing and new problems
b. Problem List Adjustment as new problems occur or as some problems change relevance or status
c. Maintenance Issues in your problem list
i. Diet
ii. Fluid Orders, Current orders & volume status
iii. Foley Catheter
iv. Telemetry
v. Central Lines
vi. Activity Orders, BMAT, PT, OT & Compliance with activity orders
vii. Skin Integrity
viii. Bowel Status
ix. DVT Prophylaxis
x. Adjustments required relevant to NPO, blood sugars, anticoagulation, preparation for procedures
d. Discharge Planning
i. Discharge location
ii. Medications & Medication Reconciliation including drug interactions
iii. Outpatient Follow-up
iv. DME & 02
v. Pending Issues

5. Life-long Learning
a. Competently address core question and identify a learning question for the day.

updated clinical assessment of status and severity for each problem. use guideline based diagnostic and evaluative criteria. integrate this pasted information into the assessment and plan. organize the assessment and plan by problem in order of severity and acuity. Each problem should have a clinical assessment of that problem's status and then orders and plan to address that problem. Use evidence based and guidelines for assessment. Ensure orders are evidence based and gold standard for each problem.. use the most updated information for each problem and include problems or abnormalities not addressed.

Result - Copy and paste this output:

Sandbox Metrics: Structured Data Index 0, 337 boilerplate words
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