Scribd
Upload
14K views

Hospital Follow Up Progress Note MedicalTemplate

The hospital follow up visit MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers working in hospitals. The hospital follow up visit MedicalTemplate contains prompters and space for all the required elements for a E&M encounter. * History o Chief complaint o History of present illness o Past medical and surgical history o Social history o Family history o Review of systems * Examination * Medical Decision Making o Review of data (labs, tests, imaging, old records) o Assessment and plan

Uploaded by

e-MedTools
Copyright
© © All Rights Reserved
14K views

Hospital Follow Up Progress Note MedicalTemplate

The hospital follow up visit MedicalTemplate is suitable for hospitalists, internal medicine physicians, family practice physicians, and other health care providers working in hospitals. The hospital follow up visit MedicalTemplate contains prompters and space for all the required elements for a E&M encounter. * History o Chief complaint o History of present illness o Past medical and surgical history o Social history o Family history o Review of systems * Examination * Medical Decision Making o Review of data (labs, tests, imaging, old records) o Assessment and plan

Uploaded by

e-MedTools
Copyright
© © All Rights Reserved
You are on page 1/ 1

Daily Progress Note Code Status ‰Full Code ‰Do Not Attempt Resuscitation ‰Comfort Care Patient Care

t Care Patient Care Time


Date Chief Complaint/Reason For Visit Start time
Stop time
Review of Systems History of Present Illness ‰ Patient is Nonverbal Data Reviewed
See HPI WNL  ‰Past Medical History
‰‰ Constitutional 
‰‰ Eyes  ‰Social History
‰‰ ENT  ‰Family Medical History

‰‰ Cardiovascular  ‰Allergy list
‰‰ Respiratory  www.e-medtools.com ‰Medication list
‰‰ Gastrointestinal 

‰Labs/Tests
‰‰ Genitourinary
‰‰ Musculoskeletal  ‰Old Chart
‰‰ Skin ‰ECG

‰‰ Neurologic  www.e-medtools.com ‰Nursing Notes & Vitals
‰‰ Endocrine ‰Radiology studies
‰‰ Psych ‰Pain present Location Quality Duration
‰‰ Heme/Lymph Level (1-10 Scale) ‰1 ‰2 ‰3 ‰4 ‰5 ‰6 ‰7 ‰8 ‰9 ‰10
‰‰ Allergy/Immun ‰Ambulating ‰Bedridden ‰Oral intake appropriate ‰Moving bowels (BM in last 24hr )
Lines and Monitors Physical Exam ‰
✔ Check indicates findings are within normal limits, or trait is present Labs & Radiographics
‰Telemetry Vitals T P www.e-medtools.com
R BP / Sats Wt
‰Chest tube \____/
‰Trach Size Vent Mode Rate Tidal Volume %FiO2 PEEP PS / \
‰Endotracheal tube
‰NG/ND tube Const ‰General ‰Sedated but arousable ____ / ____ / ____ /
‰PEG/PEJ tube Eye ‰Conjunctivae ‰Pupils ‰Discs \ \ \
‰Foley catheter www.e-medtools.com
ENT ‰Pharynx ‰Nasal mucosa ‰External ears 
‰Ostomy 
‰Central line/PICC Resp ‰Auscultation ‰Effort ‰Percussion ‰Palpation
Site CV ‰Ausc ‰Palp ‰Edema ‰Carotids ‰Aorta ‰Fem pulses ‰Pedal pulses
‰No evidence infection GI ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰Guaiac
‰Peripheral venous access Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength
Site
 ‰No evidence infection Skin ‰Inspection ‰Palpation
www.e-medtools.com
Neuro ‰Cranial Nerves ‰Deep Tendon Reflexes ‰Sensation ‰Orientation
Psych ‰Affect ‰Insight ‰Memory
Abnormal Findings ‰Lethargic ‰Obtunded ‰Combative

www.e-medtools.com
Care Coordinated With Impression Plan
‰HCPOA ‰Labs
‰PCP ‰Cultures
‰Consultants ‰Blood‰Sputum‰Urine
‰Case Management ‰Radiographs
‰Social Worker ‰Cardiac Stress Testing
‰Pharmacy ‰ECHO
‰Nutrition team ‰PFTs
‰Physical therapy ‰Aggressive pulm toilet
‰Respiratory therapy ‰DVT prophylaxis
‰Speech Therapy ‰Stress ulcer prophylaxis
‰Nursing staff ‰Daily sedation vacation
Estimated Day of Discharge
‰Head of bed elev > 30°
‰Intense glycemic control
‰Changing central lines
Plan to discharge to
C-FNP or PA-C Signature
‰Physical/Occupation Tx
‰Hospital I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this ‰Swallow evaluation
‰Home patient with the NP or PA above and I agree with the assessment and plan as outlined.
‰Pneumo vac before d/c
‰Nursing Home Physician Signature
‰Flu vac before d/c
Nature of presenting problem ‰Minimal ‰Self-limited or minor ‰Low severity ‰Moderate severity ‰High severity
Exam ‰Problem focused ‰Expanded problem focused ‰Detailed ‰Comprehensive
Complexity of Medical Decision Making ‰Straightforward ‰Low ‰Moderate ‰High Encounter Code

You might also like