|
Follow-up Progress note
|
|
|
Facility: free text
|
Room
|
|
Admit Date is required:
|
|
|
admit date
|
|
|
Interim Notes
|
|
|
Status since the last visit:
|
Interim Notes-free text
|
|
new symptom (common)
|
how many days?
|
|
associated with
• • •
|
It is described as
• • •
|
|
Subjective/Review of systems:
|
|
|
Subjective/Review of systems:negatives
• • •
|
freetextSubjective / Review of systems
|
|
Medications review
|
Medication review free text
|
|
Labs reviewed
• • •
|
Lab notes
|
|
Physical Assessment:
|
|
|
Vital signs: as above.
|
|
|
Quick PE normals:
• • •
|
|
|
select General /Constitutional
• • •
|
abnml free textGeneral /Constitutional
|
|
select HEENT
• • •
|
abnml freetextHEENT
|
|
select Lungs
• • •
|
abnml freetextChest/Lungs
|
|
selectCardiac/Vascular
• • •
|
abnml freetextCardiac/Vascular
|
|
|
abnormal free textBreasts
|
|
select Abdomen:
• • •
|
abnml freetextAbdomen
|
|
select lymph/edema
• • •
|
abnml freetextLymph
|
|
select GU
• • •
|
abnml freetextGU
|
|
select Musculoskeletal:
• • •
|
abnml freetextMusculoskeletal
|
|
select Skin
• • •
|
abnml free textSkin
|
|
select Neuro/Psych
• • •
|
abnml free textNeuro/Psych
|
|
Tube feeding?
• • •
|
|
|
Chronic Anticoagulation?
|
anticoag free text
|
|
Assessment and Care Plan Updates:
|
|
|
Overall statusStatus
|
Reviewed records
|
|
Case discussed with staff
|
free textDiscussed with family/staff
|
|
Synopsis/Diagnosis free text
|
|
|
Projected Discharge Date:
|
Continue current plan
• • •
|
|
Advance Directive
• • •
|
Advance Directives-free text
|
|
Referral
• • •
|
|
