rounding
- Chart Audit
- Vitals
- Fluid status & I/Os
- Electrolytes and Friends
- Diagnostics
- Monitoring
- Meds
- Overnight Events
- Consultant / Nursing Notes
- Orders
- Status of presenting problem (S)
- 5 P’s
- Pain
- Prancing (walking)
- Pee
- Poop
- PO (Feeding, N/V)
- What needs to happen to discharge
Presentation / Documentation
Stable or Unstable
Interventions Required
Intractable Sx
progress note
- Subjective
- Interval history
- Classic first sentence, presenting complaints and reason for admission, significant diagnostics, +/- ON events
- Subjective status of presenting sx, new complaints/changes, ROS, overnight events
- Objective:
- Vital sign trends
- Remaining PE
- Fluid balance
- Electrolytes and Friends
- Diagnostics
- Assessment and Plan
- Start with admission A&P
- Must update and evolve
- Meds
- Disposition
- Start with admission A&P
hot topics
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Pulmonary: COPD, Asthma, Pneumonia, Restrictive lung disease, Lung cancer, Pulmonary embolism, and Respiratory failure
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Endocrine: Diabetes, DKA and hyperosmolar coma, thyroid disorders, and adrenal crisis.
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GI: GI bleed, Cirrhosis of liver and complications, Hepatobiliary disorders and complications, Peptic ulcer disease, GERD, Crohn’s Disease, and inflammatory bowel disease.
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Renal: Acid Base disorders, renal failure (ESRD, acute, and chronic), renal stones, nephritic and nephrotic syndromes, and electrolyte imbalances
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Rheumatology: Gout, Osteoarthritis, SLE, Rheumatoid arthritis, and Sarcoidosis.
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Infectious disease: UTI, pneumonia, Skin infections, Infective endocarditis, Influenza, HIV, Osteomyelitis, Sepsis definitions
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Hematology and Oncology: Anemia, Cancer - Lung, Colon and Breast; Preventive screening measures and treatment modalities, Platelet and WBC disorders.
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Cardiology: Coronary artery disease, ACS, CHF; what to look for in a TTE (echo): EF, diastolic heart failure, valve problems, ischemia, rhythm abnormalities, atrial fibrillation, tachycardia and bradycardia.
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End of life care decisions