Daily Progress Note

Date

Code Status ‰Full Code ‰Do Not Attempt Resuscitation ‰Comfort Care Chief Complaint/Reason For Visit History of Present Illness ‰ Patient is Nonverbal

Patient Care Time Start time Stop time

Review of Systems
See HPI WNL

Data Reviewed

‰ ‰ Constitutional ‰ ‰ Eyes ‰ ‰ ENT ‰ ‰ Cardiovascular ‰ ‰ Respiratory ‰ ‰ Gastrointestinal ‰ ‰ Genitourinary ‰ ‰ Musculoskeletal ‰ ‰ Skin ‰ ‰ Neurologic ‰ ‰ Endocrine ‰ ‰ Psych ‰ ‰ Heme/Lymph ‰ ‰ Allergy/Immun Lines and Monitors ‰Telemetry ‰Chest tube ‰Trach Size ‰Endotracheal tube ‰NG/ND tube ‰PEG/PEJ tube ‰Foley catheter ‰Ostomy ‰Central line/PICC Site ‰No evidence infection ‰Peripheral venous access Site ‰No evidence infection

www.e-medtools.com

www.e-medtools.com
‰Pain present Location Quality Duration Level (1-10 Scale) ‰1 ‰2 ‰3 ‰4 ‰5 ‰6 ‰7 ‰8 ‰9 ‰10 ‰Ambulating ‰Bedridden ‰Oral intake appropriate ‰Moving bowels (BM in last 24hr )
✔ Physical Exam ‰Check indicates findings are within normal limits, or trait is present

‰Past Medical History ‰Social History ‰Family Medical History ‰Allergy list ‰Medication list ‰Labs/Tests ‰Old Chart ‰ECG ‰Nursing Notes & Vitals ‰Radiology studies

Labs & Radiographics \____/ / \ ____ / ____ / ____ / \ \ \

Vitals

T

P Rate

www.e-medtools.com Sats R BP /
Tidal Volume %FiO2

Wt PEEP PS

Vent Mode

Const ‰General ‰Sedated but arousable Eye ‰Conjunctivae ‰Pupils ‰Discs www.e-medtools.com ENT ‰Pharynx ‰Nasal mucosa ‰External ears Resp ‰Auscultation ‰Effort ‰Percussion ‰Palpation CV ‰Ausc ‰Palp ‰Edema ‰Carotids ‰Aorta ‰Fem pulses ‰Pedal pulses GI ‰Abdomen ‰No hepatosplenomegaly ‰No hernias ‰Rectum ‰Guaiac Musc ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength www.e-medtools.com Skin ‰Inspection ‰Palpation Neuro ‰Cranial Nerves ‰Deep Tendon Reflexes ‰Sensation ‰Orientation Psych ‰Affect ‰Insight ‰Memory Abnormal Findings ‰Lethargic ‰Obtunded ‰Combative

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Care Coordinated With

Impression

Plan

‰HCPOA ‰PCP ‰Consultants ‰Case Management ‰Social Worker ‰Pharmacy ‰Nutrition team ‰Physical therapy ‰Respiratory therapy ‰Speech Therapy ‰Nursing staff
Estimated Day of Discharge

Plan to discharge to ‰Hospital ‰Home ‰Nursing Home

C-FNP or PA-C Signature
I have examined this patient, reviewed the history, labs and radiographs relevant to this patient, have discussed this patient with the NP or PA above and I agree with the assessment and plan as outlined.

Physician Signature

‰Labs ‰Cultures ‰Blood‰Sputum‰Urine ‰Radiographs ‰Cardiac Stress Testing ‰ECHO ‰PFTs ‰Aggressive pulm toilet ‰DVT prophylaxis ‰Stress ulcer prophylaxis ‰Daily sedation vacation ‰Head of bed elev > 30° ‰Intense glycemic control ‰Changing central lines ‰Physical/Occupation Tx ‰Swallow evaluation ‰Pneumo vac before d/c ‰Flu vac before d/c

Nature of presenting problem ‰Minimal ‰Self-limited or minor ‰Low severity ‰Moderate severity ‰High severity Exam ‰Problem focused ‰Expanded problem focused ‰Detailed ‰Comprehensive Encounter Code Complexity of Medical Decision Making ‰Straightforward ‰Low ‰Moderate ‰High

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