History and Physical Advice Tips Secrets

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Admit and Transfer orders

ADMIT/TRANSFER: floor, room, service, attending, residents.

DIAGNOSIS: list in order of priority.

CONDITION: good, stable, fair, guarded, critical, etc. DO NOT PUT CONDITION AS STABLE! Use "Fair". If they are stable, send them home!

VITALS: q4h, q shift, routine, per ICU protocol.

ACTIVITY: ad lib, bed rest, up to chair, ambulate tid, etc.

DIET: regular, ADA (diabetic) 1600 calorie, low sodium, clear liquid, NPO, etc.

INS AND OUTS: strict, routine, ad lib, etc.

IV FLUIDS: 0.9 NS at 120 mL/h, or at 6 hour rate, etc.

DRAINS: Foley to gravity, nasogastric tube to intermittent suction, etc.

MEDS: antibiotics, anticoagulants, antiemetics, insulin, O2, pain meds, etc.

ALLERGIES: specific medications, NKDA, etc.

LABS: CBC, chemistries, X-rays, EKGs, pulse oximetries, etc.

MONITORS: arterial line, noninvasive BP, CVP, pulse ox, telemetry, etc.

RESPIRATORY CARE: nebulizer treatments, endotracheal suctioning, etc.

DRESSING CARE: dressing changes, compression stockings, etc.

HOUSE OFFICER CALLS: Notify H.O. if BP>150/100, temp>101 deg. F, etc.

 

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Medical Notes:
Admit/Transfer Orders
Progress (SOAP) Note
Discharge Summary
Procedure Note
Discharge Summary
Off-Service Note
Pre-Operative Notes
Operative Note
Post-Operative Note
Death Note
Post-Partum Note
Delivery Note
Cardiology Progress Note and Consult

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