EPIC – ETSU H&P

ETSU H&P

Patient Name:

MRN:

Date of Admission:

Date therapy started

Attending Physician:

PCP:

Chief Complaint:

Primary issue that brought patient to the hospital

HPI: (history of present illness)

Must include 4 out of 8 medicare elements: location, quality, severity, duration, timing, context, modifying factors, associated signs & symptoms

Don’t forget pertinent positives and negatives

Remember to include EMS/ED course if relevant

Past Medical History:

Past Surgical History:

Medications:

Allergies:

Include reactions if known

Social History:

Tobacco

Alcohol

Drugs

Occupation (if relevant)

Living situation, ADLs/IADLS if >65yo

Family History:

Review of Systems:

Must include 10 organ systems to be considered complete

Physical Exam:

Must include at least 9 organ systems with 2 aspects of each

Vitals

General

Neck

HEENT

Cardio

Resp

GI

MSK

Derm

Neuro

Psych

Rectal

Pelvic

Diagnostics:

Labs (include baselines)

Micro

Imaging

EKG

Assessment:

What are they here for?

Diagnoses addressed on admission (symptoms cannot stand alone)

Document in order of severity

Plan:

What are we doing for them?

Don’t forget to document your thought process!

Diet: (include pending diets such as NPO at midnight)

Prophylaxis: DVT (don’t forget to indicate deferred & why if applicable), GI

Disposition: home, SNF, rehab, hospice (if known)

Prognosis: good, fair, poor

Code Status: FULL, DNR, DNI

Patient will be seen and discussed with attending physician, Dr. ***, and senior resident, Dr. ***. Please refer to attending addendum for any changes to the above plan.

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