fernj1975 said:
Today I had to dictate my first discharge and boy did I feel I botched it up. Are there any links anyone can provide that have generic templates for dictating?
DISCLAIMER: Use at your own risk!
* Admit/Transfer Orders
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ADMIT/TRANSFER: floor, room, service, attending, residents.
DIAGNOSIS: list in order of priority.
CONDITION: good, stable, fair, guarded, critical, etc.
VITALS: q4h, q shift, routine.
ACTIVITY: ad lib, bed rest, up to chair, ambulate tid, etc.
DIET: regular, ADA (diabetic), low sodium, clear liquid, NPO, etc.
INS AND OUTS: strict, routine, ad lib, etc.
IV FLUIDS: D5NS at 120 mL/h, etc.
DRAINS: Foley to gravity, nasogastric tube to intermittent suction, etc.
MEDS: antibiotics, anticoagulants, antiemetics, insulin, O2, pain meds, etc.
ALLERGIES: specific medications, NKDA, etc.
LABS: CBC, chemistries, X-rays, EKGs, pulse oximetries, etc.
MONITORS: arterial line, noninvasive BP, CVP, pulse ox, telemetry, etc.
RESPIRATORY CARE: nebulizer treatments, endotracheal suctioning, etc.
DRESSING CARE: dressing changes, compression stockings, etc.
HOUSE OFFICER CALLS: Notify H.O. if BP>150/100, temp>101 deg. F, etc.
* Off-Service Note
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ADMIT DATE:
ADMIT DIAGNOSIS: list in order of importance.
HOSPITAL COURSE: changes over time, lab studies, procedures, results.
PHYSICAL EXAM: brief, targeted.
PROBLEM LIST: list in order of importance.
ASSESSMENT: based on above data.
PLAN: medication changes, lab tests, procedures, consults, etc.
* Progress Note (SOAP Note)
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S: patient comments or complaints, nursing comments.
O: VITALS: blood pressure, pulse, respirations, temp, weight, O2 sat.
INS/OUTS: IV fluid, PO intake, emesis, urine, stool, drains.
EXAM: physical findings.
MEDS: pertinent routine or new medications.
LABS: new laboratory or procedure results.
A: assessments based on above data.
P: medication changes, lab tests, procedures, consults, discharge, etc.
* Discharge Note
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ADMISSION/DISCHARGE DATES:
ADMISSION/DISCHARGE DIAGNOSES:
SERVICE: service name, attending, residents.
REFERRING PHYSICIAN:
CONSULTS: physicians, services, dates.
PROCEDURES: dates of surgery, lumbar punctures, angiograms, etc.
HISTORY, PHYSICAL EXAM: pertinent admission H&P and lab tests.
COURSE: summary of the treatment and progress during hospital stay.
DISCHARGE CONDITION: good, stable, fair, guarded, critical, etc.
DISPOSITION: discharged to home, specific nursing home, etc.
MEDICATIONS: discharge meds with dosage, administration, refills.
INSTRUCTIONS: activity restrictions, diet, dressing and/or cast care, symptoms to warrant further treatment, etc.
FOLLOW-UP: follow-up appointment, emergency phone number, etc.
* Preoperative Note
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PRE-OP DIAGNOSIS:
PROCEDURE: planned surgery.
LABS: CBC, chemistries, PT/PTT, urinalysis, etc.
CHEST X-RAY: note findings.
EKG: note findings.
BLOOD: not needed, type/screen or type/cross 2 units packed RBCs, etc.
ORDERS: NPO, preoperative antibiotics, skin or colon preps, etc.
CONSENT: signed and on chart (if so).
* Operative Note
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PRE-OP DIAGNOSIS:
POST-OP DIAGNOSIS:
PROCEDURE: surgery performed.
SURGEONS: attending, residents, students who scrubbed.
FINDINGS: acutely inflamed gallbladder, 4-cm. diameter cyst, etc.
ANESTHESIA: general endotracheal (GETA), spinal, local, etc.
FLUIDS: amount and type (electrolytes, blood, etc. in cc or units).
ESTIMATED BLOOD LOSS: amount in cc.
DRAINS: type and location (T-tube in RUQ, etc.).
SPECIMENS: type sent to pathology (gallbladder and cystic duct, etc.).
COMPLICATIONS:
CONDITION: stable, extubated, transferred to recovery room, etc.
* Post-Operative Note
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PROCEDURE: surgery performed.
S: patient comments or complaints, nursing comments, CHECK consciousness (alert, oriented, drowsy), pain control, etc.
O: VITALS: blood pressure, pulse, respirations, temp, O2 sat, etc.
INS/OUTS: IV fluid, PO intake, emesis, urine, stool, drains, etc.
EXAM: physical findings (incision/dressing, neurovascular status, etc.).
LABS: results of any since surgery.
A: assessment based on above data.
P: medication changes, lab tests, procedures, consults, discharge, etc.
* Procedure Note
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PROCEDURE:
CONSENT: Procedure, benefits, risks (include those of bleeding, infection, injury, and anesthesia), and alternatives explained to the patient who voiced understanding of the information and agreed to proceed with the (spinal tap, thoracentesis, paracentesis, etc.) Consent signed and on chart (if so).
INDICATION: meningitis, pleural effusion, ascites, etc.
PHYSICIAN(S):
DESCRIPTION: Area prepped and draped in a sterile fashion. (Local, spinal, etc.) anesthetic administered with (cc medication). Describe technique including instruments, body location, occurrences, etc.
COMPLICATIONS:
ESTIMATED BLOOD LOSS: amount in cc.
DISPOSITION: Pt. alert, oriented, and resting; breathing nonlabored; extremities neurovascularly intact; incision clean, dry and intact; etc.
* Delivery Note
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On (delivery date, time) this (age, race) female under (epidural, pudendal, local, no) anesthesia delivered a viable (male, female) infant weighing (weight) with APGAR scores of (0-10) and (0-10) at 1 and 5 minutes. Delivery was via (SVD, LTCS, classical CS) to a sterile field. (Nuchal cord reduced.) Infant was (bulb, DeLee) suctioned at (perineum, delivery). Cord clamped and cut and infant handed to waiting (pediatrician, nurse). (Cord blood sent for analysis.) (Weight) (intact, fragmented, meconium stained) placenta with (2,3) vessel cord delivered (spontaneously, with manual extraction) at (time). (Amount) of (IV oxytocin, IM methylergonovine) given. (Uterus, cervix, vagina, rectum) explored and (midline episiotomy, nth degree laceration, uterus and abdominal incision) repaired in a normal fashion with (type) suture. EBL (amount). Patient taken to RR in stable condition. infant taken to NBN in stable condition. Dr. (name) attending.
* Postpartum Note
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S: patient comments or complaints, nursing comments, CHECK pain control, breast tenderness, quantity of vaginal bleeding, urination, flatus, bowel movement, lower extremity swelling, ambulation, breast or bottle feed, birth control type.
O: VITALS: blood pressure, pulse, respirations, temp.
INS/OUTS: IV fluid, PO intake, emesis, urine, stool.
EXAM: breath sounds, bowel sounds, fundal height/consistency, incision/episiotomy condition, lower extremity edema, Homan's sign.
MEDS: RhoGAM, pain med, iron, vitamins, stool softener.
LABS: CBC, Rd status.
A: assessments based on above data.
P: medication changes, lab tests, procedures, consults, discharge, etc.
