Discharge Note

CAUTION: This page needs to be reviewed and categorized.
CHIEF COMPLAINT:
PRINCIPAL DIAGNOSIS:
SECONDARY DIAGNOSES
COMPLICATIONS
COMORBIDITIES:
RELEVANT    PROCEDURES/OPERATIONS:
HISTORY OF PRESENT ILLNESS:
Tell a chronological history of the illness to UP    TO    THE    DATE    OF    ADMISSION.
PROBLEM LIST
RELEVANT    LABS
RELEVANT    IMAGING
RELEVANT    PROCEDURES
RELEVANT    PATHOLOGY
OTHER    RELEVANT     TESTS
HOSPITAL COURSE
Tell a chronological history of the illness FROM    ADMISSION    TO    DISCHARGE.
CONSULTANTS
DISPOSITION
CONDITION ON DISCHARGE
VITALS    UPON    DISCHARGE:
PHYSICAL    EXAM    UPON    DISCHARGE
DISCHARGE MEDICATIONS:
PATIENTS FOLLOW UP CARE REQUIRED:
PCP
ISSUES TO BE FOLLOWED UP BY PCP
A. Data Gathering

1. Name, Age, Last 4
2. Chief Presenting Complaint (Not the Past History)
3. History of Present Illness
a. Past History only if it is RELEVANT to the Chief Complaint (The patient has a history of COPD and presents with shortness of breath.) Watch out for anchoring.

b. History of Present Illness
i. The patient was well until (date)
ii. Tell a chronological history of the illness to this date.

4. Past Medical History RELEVANT & Active Issues. (Don't repeat from the HPI.)
a. Include medication & dose, grouped by problem

5. Family History RELEVANT to the Present Illness. (Don't repeat from the HPI.)

6. Social History (Don't repeat from the HPI.)
a. Military Service History
b. Insurance & Finances
c. Living Situation, Support Systems, DPOA, Living Will, POLST
d. Occupation, hobbies, habits, abuses, diet

7. Review of Systems (Don't repeat from the HPI. Only relevant findings.)

8. Physical Exam (Only pertinent positives and negatives with emphasis on the details.)

9. Diagnostic Data including labs, procedures, radiology, cardiology, consultations

B. Assessment

1. Key Factors for the Admitting Concern
2. Problem Representation
3. Differential Diagnosis A provisional list of diagnoses that explain the most important Key Factors in the Problem Representation for the Admitting Concern (See the example sheet.)

4. Problem List starting with the problem relevant to the Chief Complaint and including social problems such as placement.

C. Plan for each problem on the list as well as the maintenance items of
1. Diet
2. Activity Orders
3. VTE prophylaxis
4. Mobility & Decubitus Prevention (if relevant)
5. Obstructions to progress through the hospital
6. Obstructions to discharge including housing and support and decision making.

D. Life-long Learning
1. Competently answer core, relevant questions about your patient.
2. Identify a learning question for this patient on this day.
3. Demonstrate a working knowledge of the source of the decisions about this patient including recent relevant literature and original sources.

update based on the most up to date information
use medical abbreviations and shorthand
include specific dosages, duation and frequencies iof medications

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.


CHIEF COMPLAINT:
PRINCIPAL DIAGNOSIS:
SECONDARY DIAGNOSES
COMPLICATIONS
COMORBIDITIES:
RELEVANT PROCEDURES/OPERATIONS:
HISTORY OF PRESENT ILLNESS:
Tell a chronological history of the illness to UP TO THE DATE OF ADMISSION.
PROBLEM LIST
RELEVANT LABS
RELEVANT IMAGING
RELEVANT PROCEDURES
RELEVANT PATHOLOGY
OTHER RELEVANT TESTS
HOSPITAL COURSE
Tell a chronological history of the illness FROM ADMISSION TO DISCHARGE.
CONSULTANTS
DISPOSITION
CONDITION ON DISCHARGE
VITALS UPON DISCHARGE:
PHYSICAL EXAM UPON DISCHARGE
DISCHARGE MEDICATIONS:
PATIENTS FOLLOW UP CARE REQUIRED:
PCP
ISSUES TO BE FOLLOWED UP BY PCP
A. Data Gathering

1. Name, Age, Last 4
2. Chief Presenting Complaint (Not the Past History)
3. History of Present Illness
a. Past History only if it is RELEVANT to the Chief Complaint (The patient has a history of COPD and presents with shortness of breath.) Watch out for anchoring.

b. History of Present Illness
i. The patient was well until (date)
ii. Tell a chronological history of the illness to this date.

4. Past Medical History RELEVANT & Active Issues. (Don't repeat from the HPI.)
a. Include medication & dose, grouped by problem

5. Family History RELEVANT to the Present Illness. (Don't repeat from the HPI.)

6. Social History (Don't repeat from the HPI.)
a. Military Service History
b. Insurance & Finances
c. Living Situation, Support Systems, DPOA, Living Will, POLST
d. Occupation, hobbies, habits, abuses, diet

7. Review of Systems (Don't repeat from the HPI. Only relevant findings.)

8. Physical Exam (Only pertinent positives and negatives with emphasis on the details.)

9. Diagnostic Data including labs, procedures, radiology, cardiology, consultations

B. Assessment

1. Key Factors for the Admitting Concern
2. Problem Representation
3. Differential Diagnosis A provisional list of diagnoses that explain the most important Key Factors in the Problem Representation for the Admitting Concern (See the example sheet.)

4. Problem List starting with the problem relevant to the Chief Complaint and including social problems such as placement.

C. Plan for each problem on the list as well as the maintenance items of
1. Diet
2. Activity Orders
3. VTE prophylaxis
4. Mobility & Decubitus Prevention (if relevant)
5. Obstructions to progress through the hospital
6. Obstructions to discharge including housing and support and decision making.

D. Life-long Learning
1. Competently answer core, relevant questions about your patient.
2. Identify a learning question for this patient on this day.
3. Demonstrate a working knowledge of the source of the decisions about this patient including recent relevant literature and original sources.

update based on the most up to date information
use medical abbreviations and shorthand
include specific dosages, duation and frequencies iof medications

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, 491 boilerplate words
Questions/General site feedback · Help Ticket

Send Feedback for this SOAPnote

Your email address will not be published. Required fields are marked *

More SOAPnotes by this Author: