You are on page 1of 2

Hosp Meds Daily Labs & Vitals PCP: Days

VS: __ yo M Others: Hosp:


Line:
Labs: h/o: Foley:
p/w:
for:
USHU:

VS:

Labs:

PmHx Meds PsHx All SHx


1.Tob:
2. EtoH:
VS: 3. Drugs:
4.Lives:
Labs: 5.ADLs:
6.Work:
FHx 7. Vaccine:

8. Screen:
VS:

Labs:

PEx: Presentation Labs


VS:
W:
BMI:
VS:
Relevant PE:
Labs:

NQI/PS PL Old Relevant Imaging: Proc / Imaging / Cx


DVT: a/f:
n/w:
Code:

Surrogate:

Vaccine:

Smoking:
Daily Presentations: iSOAP
Intro: One liner "Mr Williams is here with CHF"
Fill us in on what happened since team rounds ended
yesterday and the start of your day today.

If the team or night float did something before you


came in, include the lab/vitals, the intervention, and the
�ubjective: response

If you or the team did something today with new labs,


vitals, or imaging today, hold that data for Objective
and plan.
Vitals First: List the vitals, with 24 hour ranges

Physical Exam: relevant to the principal diagnosis

Labs: only from today; don't give yesterday's labs


Qbjective: today. Whether you say them all or only a select few is
attending dependent.

Imaging: Say what it means, don't read the report

Cultures: Every day, even if negative


One line that includes the principal diagnosis and the
Assessment: velocity the patient is taking - better, worse, the same?
Try to use CMS language
List the principal diagnosis first, and say what we are
doing for it. Just say what you are doing today, if you
f>_lan by
summarize or justify, you failed the presentation.
Problem:
Then each problem, with the more active ones on top

WB%:t
Hgb
MCV

Na Cl BUN
[a
Glu Mg
Hct K CO2 Cr
RDW
N: L: M: B: E:

TP Alb T.Chol
HDL
T. Bili D. Bili PT I PTT �
LDL
AST ALT
Trig

ALP