Notes Flashcards
when would you write a comprehensive H/P?
new patient
annual physical exam
DOT physical
a note that is written daily, usually during a hospital stay, really short
progress note
includes informed consent, anytime for a procedure that isn’t a surgery
procedure note
Note used for brief encounter for one or two problems
focused SOAP
What is included in a focussed SOAP note?
CC Brief HPI ROS- pertinent FH, SH, PMH, etc. PE A/P
give a synopsis of care up to point of transfer. story to the next person taking care of the patient
Admit/ Transfer orders
what is included in an admit order?
Identifying info admit/transfer diagnosis condition vitals (how often to take) activity Diet Fluids Rx Allergies
what part of the note includes patient concerns, comments, updates, nursing notes
Subjective
What part of the note includes changes to care, Rx, specialty consultations, discharge
Plan
What part of the note includes vitals, updates on labs, PE, Rx
Objective
What part of the note includes assessment based on admission, surgical info and above info
Assessment
one of the most important things to ask when rounding in the hopsital
pain control
includes everything for a patient during their stay in the hospital. Ensures continuous patient care, education
Discharge note
labs for pre-op clearance
CBC chem PT/PTT UA, blood typing
what is included in the description of procedure in the procedure note
prepped and draped sterile, anesthesia/pain control, technique and instruments, body location, sutures (number, type of material, technique)
