EPIC – ETSU Progress Note

ETSU Progress Note

Overnight events and interval history:

Medication Data:

Antibiotics including #days and stop date if known

IVF/Drips

Scheduled meds

PRN meds

Physical Exam:

Vitals:

General:

HEENT:

Cardio:

Resp:

GI:

Ext:

Derm:

Neuro:

Psych:

Diagnostics:

Labs

Micro

Imaging

EKG:

Assessment:

List of active diagnoses addressed during today’s visit

Optional to include chronic/resolved diagnoses IF brief summary of plan detailed below

Plan:

Active plan of care for each diagnosis listed above

Summary of Today’s Plan:

Optional if only pertinent/daily assessment noted above

Must be included if detailed A/P includes resolved issues in order to provide a more clear/improved transition of care

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 Dr. ***. Please refer to attending addendum for any changes to the above plan.

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