Use this example template to create a patient log & use the information provided at the end and make up the vital signs or additional information that is missing.
S Subjective: start with cc, why they are here, when did it start, how long it lasted, what did they do to intervene, ……keep it narrow but include cc, and what other subjective findings, do not go into too much details…..
PMH (in short as Dx), list all of them
O Objectives: Include ROS (either include minimum 12 systems – very short not detailed, or state “All 12 systems reviewed and negative except HPI” V.S, Lab findings (only abnormal values not all lab results, Imaging – interpretation only)
A Assessment Physical Exam (the most important one, short to the point, but address from head to toe), not the way templates have it, if you use them remove things you DID NOT assess, and bold the abnormal findings during your assessment, ex: neuro, auscultation, palpation, any asymmetry, any opened wound …..just OBJECTIVE data entry here).
P Plan: start off with cc: what is found short based on lab, imaging, or assessments, than continue what was ordered, consulted, or what was continued and recommended
ex: Acute Abdominal pain – 8/10 pain scale, LLQ, CT A/P reviled diverticulitis
Initiated IVF NS @125ml/hr, Abx empirically Zosyn
pain management with PRN Morphine 0.5 mg IV Q6 hr for severe pain, follow blood and urine cultures
elevated WBC 17000, will continue to follow trends with am labs (CBC, CMP)
Follow temperature curve, GI consulted pending evaluation, will appreciate recomendations.
Leukocytosis – WBC 17K, monitor trends, monitor Temperature curve, continue current treatment as above
AKI – …..
HTN – chronic by history, currently stable give BP values, continue to monitor, maintain MAP >65, continue Lisinopril 20 mg/Day PO
DM – ….
GI prophylaxis – ….
VTE prophylaxis – ….
CODE STATUS – FULL CODE
INFORMATION THAT IS GATHERED BELOW: to use with the above template example ^
Patient states that she has a history of several strokes and is taking warfarin. Her warfarin level yesterday was 3.9. Hematology History – Patient with a history of recurrent strokes (03/2021, 06/2021, 01/2022), and a left ventricular thrombus 2021.
– Initially treated with full dose Eliquis 5 mg P.O. twice daily.
– Repeat echo in May 2021 with thrombus no longer visualized.
– Patient with everyday gum bleed while on Eliquis. – After the 01/2022 CVA, Eliquis was deemed to be “Eliquis failure” per neurology and cardiology. She was placed on Coumadin around 02/2022 + ASA and is followed at the South Miami Hospital Coumadin clinic. – APLS workup was negative for antiphospholipid syndrome. Negative Lupus anticoagulant, Beta 2 glycoprotein, and cardiolipin. JAK2 V617F mutation negative. SPEP with immunofixation showed no monoclonal protein. Interval History/HPI – Ms. KJA is a 47 y/o lady that hematology is following for her hx. of APLS, CVA, in need for Coumadin bridge.
– PMHx: iron deficiency anemia, anxiety, HTN, hypothyroidism, PCOS, seizures, sleeve gastrectomy 2011, distal branch left MCA stroke, thoracic descending aortic aneurysm, migraines, menorrhagia, HELLP syndrome, left ventricular thrombus 2021, and covid + 01/2022. She has never had a mammogram, colonoscopy or EGD. Tobacco abuse (1/2 ppd x 20 yrs), stopped 03/2021.
This morning’s laboratory workup reviewed including hemoglobin 11.4, hematocrit 37.3, WBC 6.75, platelet count 347K, INR 2.1, creatinine 0.82 with a clearance of 78.1, UA positive, FOBT negative. APRN Recommendations:
— Continue with Lovenox/Coumadin bridge.
— Monitor counts with daily CBC.
— Iron studies ordered.
— Continue with inpatient supportive care.
She has Coumadin Clinic follow up and per patient she has Lovenox at home to continue bridging.
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