Date of Admission:
Date therapy started
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:
Include reactions if known
Occupation (if relevant)
Living situation, ADLs/IADLS if >65yo
Review of Systems:
Must include 10 organ systems to be considered complete
Must include at least 9 organ systems with 2 aspects of each
Labs (include baselines)
What are they here for?
Diagnoses addressed on admission (symptoms cannot stand alone)
Document in order of severity
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.