History and Physical Advice Tips Secrets

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Off Service Note

This note is to let the oncoming physicians and residents know what is going on with the patient when you are leaving the service. Especially important if the patient has had a long hospital stay, ICU, etc.

ADMIT DATE:

ADMITTING DIAGNOSIS: list in order of importance.

HOSPITAL COURSE: Tells the story of the patient from when they were admitted until now, changes over time, lab studies, procedures, results.

PHYSICAL EXAM: brief, targeted.

PROBLEM LIST: list in order of importance.

ASSESSMENT: based on above data.

PLAN: medication changes, lab tests, procedures, consults, etc.

 

 

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History & Physical

Consult

Common Night Calls

Patient Tracker Sheets

Antibiotic Guide

ABG Calculator

Drug Guide
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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

Learn how to do an H&P correctly!

 

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The money is in the assessment and plan!