INTERIM PROGRESS NOTE/MULTIUSE

PATIENT: 	|PATIENT NAME FIRST,LAST| |PATIENT SSN|
ADMIT DATE:	|ADMISSION DATE|
ADMIT DX: 	|ADMITTING DX|

ID

|PATIENT NAME FIRST,LAST| is a |PATIENT AGE| year-old |PATIENT SEX| admitted for |ADMITTING DX|. 

24 HOUR EVENTS
TELE

SUBJECTIVE
In the subjective section, start the note by identifying previous notes that were reviewed by referencing the past notes into the current note.  However, copying and pasting previous notes should be avoided given the risks of inclusion of irrelevant or inaccurate information as well as the risk of excessively long notes. Ensure the documentation of the patient’s chief complaint(s) and any new problems are clearly stated. Also, document the patient’s degree of adherence to the treatment plans from the previous visits.

PROBLEM LIST BRIEF
OBJECTIVE
VITALS
PHYSICAL EXAM
Ins:
Outs:
Total
ACTIVE MEDICATIONS
LABS

|HS:SCL1-CBC-AFTER10/14-5;10Y| 
|LAB-SODIUM;1;1Y|
|LAB-POTASSIUM;1;1Y|
|LAB-CHLORIDE;1;1Y|
|LAB-CO2;1;1Y|
|LAB-BUN;1;1Y|
|LAB-CREATININE;3;1Y|
|LAB-GLUCOSE;1;1Y|
|LAB-CALCIUM;1;1Y|
|LAB-MAGNESIUM;1;1Y|
|LAB-PHOSPHORUS;1;1Y|
|LAB-PROTEIN,TOTAL;3;1Y|
|LAB-ALBUMIN;1;1Y|
|LAB-AST;1;1Y|
|LAB-ALT;1;1Y|
|LAB-ALK PHOS;1;1Y|
|LAB-BILIRUBIN,TOTAL;1;1Y|
|LAB-PT;3;1Y|
|LAB-PTT;3;1Y|
|LAB-INR;3;1Y|
|LAB-A1C;1;1Y|
|LIPID PROFILE|
|LAB-UA;1;1Y|


RELEVANT    CULTURES

RELEVANT    IMAGING

RELEVANT    EKG/ ECHO

RELEVANT    PROCEDURES

RELEVANT    PATHOLOGY

ASSESSMENT AND PLAN
PREP is a common mnemonic used in speaking which stands for Point, Reason, Example, Point. I think a modified version can help here.

Instead of Problem, Status, Plan, you can use PREP: Problem, Reason (etiology), Evaluation (status), Plan

If you don’t know the etiology, you can write, “unknown” or “likely due to”. If you know you use 2/2.

Write an effective problem statement.
2. Write out a detailed list of problems

From history, physical exam, vitals, labs, radiology, any studies or procedures done, microbiology write out a list of problems or impressions.
3. Combine problems

Instead of doing a problem based where you list every single problem, try to combine the problems and either used a system based approach or an approach that links primary problems with secondary problems that are likely caused by the primary problems or go together and are treated together.

|PATIENT NAME| is a |PATIENT AGE| year old |PATIENT SEX| veteran admitted for |ADMITTING DX|


Principal Diagnosis

ACTIVE Comorbidities
Other Comorbidities

CHECKLIST

Diet: 		
Analgesia:
DVT PPx'
GI Ulcer PPx
Bowel Regimen
Glycemic Control
Antibiotics
Sleep Regimen
Lines
Drains    
Folley
Disposition
Code Status