when writing progress notes, how far do you go back on meds?

[hippocampus]

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for example, let's say they are taking a drug "1 tab PO daily."
you have to write a progress note in the morning.
how far do you go back?
do you look at the DATE or TIME the drug was given?
do you include IV fluids?

 

[gutonc]

for example, let's say they are taking a drug "1 tab PO daily."
you have to write a progress note in the morning.
how far do you go back?
do you look at the DATE or TIME the drug was given?
do you include IV fluids?

Progress notes should include every drug they're taking that day, unless you're in an EMR system where that info is easily retrievable (and probably easier to look at than if you pasted/typed it in the note). Drugs being given for Y days should be noted as Day X of Y or something like that. I only write PRNs if their relevant. Nobody cares about the tylenol PRN fever in a person admitted w/ DKA but they do care about how much of their sliding scale insulin they got after the drip was turned off.

 

[McLovin]

I think only significant meds need to be included in the daily note. Maybe its just me, but if I want to know for sure what meds a patientis taking I go straight to the MAR, not the intern daily note.

 

[orientedtoself]

another vote for every scheduled med, including iv, including doses. example: asa 81mg po daily