Good Templates for History and Physicals/Progress Notes
Started by Lodoc
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If you're just looking for general templates - the studentdoctor.net home page has links to downloadable templates.
If you want PM&R specifc I don't think they have any there...
If you want PM&R specifc I don't think they have any there...
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Lodoc said:
Is your institution looking to have a computerized in-patient progress note in the near future? I've seen a few different ones, but it certainly does save some time, especially if information gets updated daily on the computer and the forms for each patient are just printed out in the morning. They don't seem to be much different from other computerized forms except for having space to put in functional progress, area in the plan for standard stuff like GI/DVT prophylaxis, bowel/bladder, etc. I could be wrong though..
Unfortunately, our H&P forms are printed out - it's 14 pages long.
HPI, Meds, Allergies, code status, current diet, PMH, PSH, pertinent lab results and imaging results, LONG social history (marital status, who lives with pt? how many steps to house, to bed room, bathroom, occupation, tobacco, drugs, alcohol), pre-morbid functional status, current(within a day or two of admission) functional status (dressing, ambulation, transfers, etc.), physical exam including a detailed neurologic exam, assessment and plan including impairments and disability, goals, factors that may interfere with pts reaching their goals (pain, endurance, etc.), plan by system (DVT, GI proph, cards, endocrine, etc. etc.) and 4 more billing/coding type stuff that the attending fills out.
HPI, Meds, Allergies, code status, current diet, PMH, PSH, pertinent lab results and imaging results, LONG social history (marital status, who lives with pt? how many steps to house, to bed room, bathroom, occupation, tobacco, drugs, alcohol), pre-morbid functional status, current(within a day or two of admission) functional status (dressing, ambulation, transfers, etc.), physical exam including a detailed neurologic exam, assessment and plan including impairments and disability, goals, factors that may interfere with pts reaching their goals (pain, endurance, etc.), plan by system (DVT, GI proph, cards, endocrine, etc. etc.) and 4 more billing/coding type stuff that the attending fills out.
