I feel completely incapable of doing any of that stuff.
Again, I didn't either, but some helpful M4's gave me pointers. Don't worry about this stuff until sometime in late June, but while I'm thinking of it I'll start passing them along...
Things I wish I'd known in July of my M3 year (with special thanks to Heather K, MCW class of 2007):
How to write a daily progress note:
S: Begin with a one-liner about your patient, and how things were overnight. (Pt. Smith is a 45 yo male admitted for acute exacerbation of COPD, no acute issues overnight). Some services may omit the patient info, and just focus on how things were overnight. Especially if the patient is well known to the service. Also include hospital day or post-op day if pertinent. The best source for how things went overnight is to ask the nurses directly.
Be nice to nurses, and your life will be easier, you can also read the nursing notes.
O: (vitals, physical, and labs)
VS: Current Temp (Tc), maximum temp (Tmax).
Ranges of vitals: BP, HR, RR for past 24 hours.
Ins/Outs: Include totals for past 24 hours, and divide Ins into PO, IV fluids, Blood, etc. Outs will include urine, poop, and drains (surgical drains, chest tubes, etc).
Gen: A brief note on how the patient looks when you walk into the room (resting comfortably, in respiratory distress, etc)
HEENT: Assess what is important. Check mucous membranes for moisture if the patient is dehydrated, or neck for rigidity or whatever is pertinent.
CV: Common abbreviations: RRR (regular rate and rhythm), no m/r/g (no murmurs, rubs, or gallops). Document pulses and capillary refill. Assess PMI and JVP if needed.
Resp: Common abbreviations: CTAB (clear to auscultation bilaterally). If you hear something, document it. Include if inspiratory, expiratory, or both.
Abdomen: Common abbreviations: soft/NT/ND (soft, non-tender, non-distended). Assess organomegaly, hernias, etc.
Extremities: You don't need to do a full exam every day, but if something changes, note it. Common abbreviations: MAES (moves all extremities spontaneously [infants and kids]) Include gait here if it's pertinent.
Skin: Note rashes, moles, lumps, bumps, incisions (c/d/i = clean, dry intact). Comment on turgor is pertinent.
Neuro: A&O x 3, EOMI, CN II-XII intact, ect.
Labs:
Always last CBC, Basic chem, whatever is new that morning. If things are out of whack, make note of the previous day or two so you can comment on trends. i.e. elevated white count, falling hematocrit, etc.
A: Again, a one-liner about your patient, their problem, and how they are doing. I.e. Pt. Smith is a 45 yo male patient with a PMH of COPD, admitted for acute exacerbation of COPD, currently improved/stable/etc.
P: Address issues identified in the assessment. A good way to do this is by system. You can also do it by individual issue.
CV: no issues, or angina, or CHF, or asthma. Identify problem, and plan your treatment.
Resp: Exacerbation of COPD, continue combivent neb treatments q4h, etc, etc.
FEN/GI: (fluids, electrolytes, nutrition/GI): advance diet, supplement Mg, K or whatever.
ID: Afebrile vs. patient on day 3/7 of ciprofloxacin vs. no issues, or whatever. Also a good place to comment on the white count, left shift, etc...
Heme: Any H/H issues, does the patient need blood, platelets?
Neuro: Good place for pain management issues.
Disposition: Comment on the patient's continued need for hospitalization, or if they can go to the floor from the ICU, or home.
Eventually, you'll be able to omit a good portion of that stuff for your day to day patients, and by no means do you need to do it like that every time. If you can write a good thorough note (medicine service, often multiple pages long), you'll eventually be able to omit the fluff and focus on the important stuff (surgery service, 1/2 page
max).
Honestly, I'm just not familiar with the workings of a hospital.
