Template for following patients??

[NRAI2001]

The intern I was working with last had a template that she used to follow in-patients she had.. I forgot to copy it before she left; Does anyone have a good template they use to follow patients? Those little pocket notes where you can track a patients SOAP note info (vitals, meds, ...etc) for multiple days??

Thanks

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[newbie04]

http://medfools.com/downloads.php

 

[OveractiveBrain]

Edit: I just saw newbie04's post. Thats pretty awesome. use the one at the top

I tried desperately to find something that would work for me. I tried making my own, printing some out, some the size of 8.5x11, some the size of a notecard, nothing really stuck for me.

The system I use now is simply an 8.5x11 sheet of paper folded in half. HPI pertinents and initial labs / problems and medications on the front, then daily tracks of laboratories and check-boxes throughout. The paper is folded in half, so I have about 3 blank "pages." Each page holds enough space for 2 days. That means if the patient lasts longer than 6 days, Im SOL, oh well. I would track medication days on the front, and cross off meds we discontinued. The papers are small enough so that they dont flop all around from your white coat (making you look disheveled) but are large enough to contain copied notes from the morning to help you present, printed paperwork or documentation, discharge notes for the patient, etc.

I think you will find that most of the pre-fabbed designs work ok. I never found one that was awesome, that worked as well as the system I used, or that had the ability to track all of the data attendings would prompt me for. I always had to add my own little deal on each one, so I stopped using the pre-fabs.

 

[McGillGrad]

We write it down by hand for every patient, so you get it in your head after a few weeks.

The problem with proformas is that they make it more difficult to internalize the info in your head.

 

[alwaysaangel]

We write it down by hand for every patient, so you get it in your head after a few weeks.

The problem with proformas is that they make it more difficult to internalize the info in your head.

THIS THIS THIS THIS THIS!

Having the pre-made H&P forms, and daily track forms is all well and good because it lets you be relatively brainless when collecting. But you are WAY better off creating your own and writing it by hand for each patient so that you really get in your head what and H&P consists of, what the daily labs consist of, what the vitals consist of etc. Otherwise you'll be at the end of your 3rd year and still wont really have it down so naturally that you can do it at 3am when you're exhausted.

 

[ANCAdoc]

I might be spoiled, but all of our hospitals (university, county, private, VA) have an EMR with a "rounds reports" feature that prints impt info (vitals, meds, labs, radiology reports, and even last note) on 1-2 pages.

With EMR technology, it is a pretty simple thing for IT people to design. I mean, all the info is in the computer. 3 of our 4 hospitals have different EMRs but every one has a rounds report feature.

It's awesome for residents and even med students - they no longer have to go around writing down vitals, etc.

 

[McGillGrad]

I might be spoiled, but all of our hospitals (university, county, private, VA) have an EMR with a "rounds reports" feature that prints impt info (vitals, meds, labs, radiology reports, and even last note) on 1-2 pages.

With EMR technology, it is a pretty simple thing for IT people to design. I mean, all the info is in the computer. 3 of our 4 hospitals have different EMRs but every one has a rounds report feature.

It's awesome for residents and even med students - they no longer have to go around writing down vitals, etc.

EMR is the future so we need to adapt. As long as you can still roll into the hospital when the computers are down and do it all by hand, then it's all good.

Writing down values or rewriting information is a waste of time, but hand-writing the important sections of the H&P cannot be replaced by ticking a list of boxes on a form.

 

[ANCAdoc]

Writing down values or rewriting information is a waste of time, but hand-writing the important sections of the H&P cannot be replaced by ticking a list of boxes on a form.

True. That's why the rounds reports should ideally include your last note.

Since we've went totally EMR with rounds reports, I haven't written much down, cutting out a significant amount of time in the morning. I have all of my info in about 20 seconds.

 

[45408]

I might be spoiled, but all of our hospitals (university, county, private, VA) have an EMR with a "rounds reports" feature that prints impt info (vitals, meds, labs, radiology reports, and even last note) on 1-2 pages.

With EMR technology, it is a pretty simple thing for IT people to design. I mean, all the info is in the computer. 3 of our 4 hospitals have different EMRs but every one has a rounds report feature.

It's awesome for residents and even med students - they no longer have to go around writing down vitals, etc.

True. That's why the rounds reports should ideally include your last note.

Since we've went totally EMR with rounds reports, I haven't written much down, cutting out a significant amount of time in the morning. I have all of my info in about 20 seconds.

Ugh, this would make my life so much better. I indeed waste an absurd amount of time on this stuff.

 

[ShyRem]

Mine too.