ตัวอย่างการเขียน Progress note

Subjective คือ ปัญหาที่ผป

ู้ ว
่ ย complaint, บรรยายสิ่ ง/ประเด็นที่ นศพ สนทนากับผูป
้ ว
่ ยเช่ น
ปวดศี รษะ ปากแห้ง คอแห้ง ท้องผูก อาการนอนหลับมากเกินไป เจาะเลือดไปแล้วแต่ไม่ทราบผลเลือดรู ้สึกกังวล กังวลเรื่อง
โรค อยากกลับบ้านลูก หลานไม่มาเยีย
่ ม คุยกับพยาบาลไม่เข้าใจ กลัวตาย ไม่มท
ี ี่ยด
ึ เหนี่ยวจิตใจ
ถามจากพยาบาลพบว่าผูป
้ ว
่ ยรบเร้าขอกลับบ้าน ไม่ค่อยรับฟังพยาบาล
Objective คือ sign and symptoms ที่ นศพ ตรวจพบสอดคล้องกับ subjective เช่ น
o
Vital sign T 38 C BP 150/90 mmHg PR 110 bpm RR 20/min
HEENT mild pale conjunctiva, no icteric sclera Heart & Lung: WNL Abdomen: decrease bowel sound, mild distention,
soft, not tender
MSE: GA ผูป
้ ว
่ ยชาย ให้ความร่วมมือ สบตาดี ท่าทางอ่อนเพลีย Psychomotor: retardation Mood: Depress, Anxious Affect:
Appropriate Thought: deny suicidal idea, preoccupation เรื่องการขอกลับบ้าน กลัวตาย ไม่มท
ี ี่ยด
ึ เหนี่ยวจิตใจ
Perception: deny hallucination Sensorium & cognition: drowsiness, orientated to time, place, person
จาก nurse note: ถ่ายอุจจาระครั้งสุดท้าย 5 วันก่อน, ไม่มญ
ี าติมาเยีย
่ มเลยตั้งแต่นอนรพ.
Lab: Hb 7.4 Hct 23 WBC 19820
Assessment คือ เขียนประมวลปัญหาที่ประเมินได้ แยกเป็นข้อๆ เช่ น

ปัญหาทางกาย 1.Ischemic stroke, hypertension อธิบายอาการปวดศี รษะ, ท้องผูกเนื่องจากไม่ได้เคลื่อนไหว

2.Fever, unknown origin อธิบายอาการไข้ อ่อนเพลีย ปวดศี รษะ
3.Side effect from amitriptyline อธิบายอาการปากแห้ง คอแห้ง ท้องผูก อาการนอนหลับมาก
4.Anemia อธิบายอาการอ่อนเพลีย

ปัญหาทางจิตเวช 1.Major depressive disorder อธิบายซึ มเศร้า อ่อนเพลีย

ปัญหาทางสั งคม 1.lack of support from family เนื่องจากไม่มญ

ี าติมาเยีย
่ มเลย
2.poor compliance เนื่องจากไม่ร่วมมือกับการรักษา

ปัญหาทางจิตวิญญาณ 1.lack of spiritual support เนื่องจากกังวล กลัวตาย ไม่มท

ี ี่ยด
ึ เหนี่ยวจิตใจ

Plan คือ เขียนแผนการรักษาที่สอดคล้องกับปัญหาที่ประเมินได้ แยกเป็นข้อๆ เช่ น

ปัญหาทางกาย 1.Ischemic stroke, hypertension ให้ยาลดความดันโลหิต ชื่ อ .................ขนาด............plan ให้ยา

…………….. วัน รอฝึกกายภาพบำบัด กระตุ้นการขยับตัว
2.Fever, unknown origin กำลังตรวจหาสาเหตุของไข้ ทำ H/C และให้ยา ABO ชื่ อ .................
ขนาด............plan ให้ยาฉีด 7 วัน
3.Side effect from amitriptyline พิจารณาเปลี่ยนยาเป็นกลุ่มอื่น ให้ดื่มน้ำ รับประทานผักผลไม้
4.Anemia อธิบายอาการอ่อนเพลีย

ปัญหาทางจิตเวช 1.Major depressive disorder อธิบายซึ มเศร้า อ่อนเพลีย

ปัญหาทางสั งคม 1.lack of support from family เนื่องจากไม่มญ

ี าติมาเยีย
่ มเลย
2.poor compliance เนื่องจากไม่ร่วมมือกับการรักษา

ปัญหาทางจิตวิญญาณ 1.lack of spiritual support เนื่องจากกังวล กลัวตาย ไม่มท

ี ี่ยด
ึ เหนี่ยวจิตใจ
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