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Resident Physician: Kenneth Acha, MD, UCR FM PGY2 Attending Physician: Consulting Physician: Reason for care: Medication management / Psychotherapy / 5150 Discussed & Coordinated Care with: CC & HPI / INTERIM HISTORY DATE LAST SEEN: SINCE LAST SEEN:...
NOTES
Resident Physician: Kenneth Acha, MD, UCR FM PGY2 Attending Physician: Consulting Physician: Reason for Consult: Substance abuse / Anxiety / Depression HISTORY OF PRESENT ILLNESS: PAST PSYCHIATRIC HISTORY. Patient denies psychiatric problems in the past....
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ATTENDING: RESIDENT: Dr. Kenneth Acha, PGY2 CONSULTANTS: PROCEDURES PERFORMED: REASON FOR SERVICE: SUBJECTIVE: Patient seen at bedside. NAEO. Patient improving clinically. -No N/V/D. -No CP, Palpitations. -NO SOB, Tachypnea. -No Fever / Chills. OBJECTIVE: Vital signs....
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From Ventura Family Medicine Residency. NEWBORN WT/COLOR CHECK SUBJECTIVE: _-day old infant born to a _ year old G_ at _ weeks by _. No pregnancy or delivery problems. Mother was blood type _, HBsAg neg, rubella immune, GBS _, other labs also unremarkable. In the...
NOTES, OB/GYN
I use the following postpartum note for uncomplicated vaginal deliveries. I simply copy and paste in TraceVue (our OB EHR) and then edit. If there are any complications, see here. SUBJECTIVE: Pt doing well. Pain is well controlled with meds. Afebrile. No...
NOTES, OB/GYN
These are extra things I consider for complicated postpartum notes. For the basic uncomplicated postpartum note upon which I add these extras, click here. Subjective: If there is excessive vaginal bleeding, quantify. What kind of pads? How many pads at once? How often...
