NOTES, OB/GYN
Resident: Attending: CC: Abdominal cramps and back pain. HPI: 20-year-old G1P0 at 39 wks by LMP and Ultrasound at 14 weeks comes in complaining of back pain and abdominal cramps. She is on day two of Macrobid treatment for UTI. She has been having this pain for a few...
HOSPITAL MEDICINE, NOTES
Admissions Date: Discharge Date: Service: __________ ; Attending Physician: Dr. ________; Resident: Dr. _______ PCP / Referring Physician: Discharge Diagnosis: (Copy and paste problem list from last Progress Note) Consultants: Name, MD/DO, Date Name, MD/DO, Date List...
HealthCare, NOTES
Date and Time of Service: O/N Events: SUBJECTIVE: OBJECTIVE: BP: MAP: Pulse (art /cuff): RR: O2sat: Tm/Tc: BG: I/Os: Bal: UOP: Drains: Ventilator Mode: Vent rate: Tv: PIP/Pplat: PEEP: PS: FiO2: Physical Exams Gen: Neuro: HEENT: Resp: CV: Abd: Ext: Skin: Lines:...
NOTES
Date of Admission: Chief Complaint: History of Present Illness: Start with one-liner. E.g. “2 year old admitted with a presumptive diagnosis of croup.” Your one-liner should express what you think the diagnosis is. Then continue and give a supporting HPI...
NOTES
Dates of Service: Admission Diagnosis: Jaundice Discharge Diagnosis: Indirect hyperbilirubinemia Hospital Course Describe hospital course… [The Hospital course is like the History part and the physical examination below is the PE part of the H & P.] PHYSICAL...
HOSPITAL MEDICINE, NOTES
Adult H & P Form Date of Admission: Resident: Kenneth Acha, MD, UCR FM PGY2 Attending: PCP: Specialists: Reason for Admisson: HISTORY OF PRESENT ILLNESS: ____ yo M/F with a history of …. who presents with a…. At baseline, the patient...
