GUIDE LINES FOR RESIDENT’S ON LINE PATIENT DOCUMANTATION IN THE PICU

PROGRESS NOTE By Physician (PICU)

This is the Comprehensive daily Note to be Written/Completed after rounds with attending.

August 2006

TEMPLATE SECTION / INFORMATION /FORMAT GUIDELINES
4.- Clin.Assessment. / System-by-System assessment. Needs to be up-dated according to studies/ work up as discussed in attending rounds. (See addendum guidelines)
5.- Primary Dx: / May need to be up-dated according to studies/ work up as discussed in attending rounds
6.- Secondary Dx: / May need to be up-dated according to studies/ work up as discussed in attending rounds
7.- Laboratory Review: / (Y) Yes, (N) Option (Labs report may cross over from MIS lab reports)
8.Ancillary Review: / (Y) Yes, (N) Option . Click OR OK (1) and enter each relevant study.
  • Reviewed ?: Enter ER studies results available, including radiologic studies and if reports are official or unofficial. If lab. results are normal, NO NEED TO WRITE ALL THE NUMBERS.

9.- Physical Exam: / BEWARE THAT THE INITIALLY / ADMISSION / PREVIOUS PROGRES NOTE “PE” MAY POPULATES THIS FIELD AUTOMATICALLY, and needs to be review it carefullyand edited to match patient’s current condition.
1)PE all Normal “NOT AN OPTION FOR PICU NOTE”
(N) Normal. “NOT AN OPTION FOR PICU NOTE”
(U) Unchanged as of Last visit. “OPTION FOR PICU NOTE, BUT STILL NEED TO ENTER PERTINET FINDINGS AND DELETE THE SECTION OF PHSYCHIATRY THAT WIL SAY UNCHANGED.”
2)# PE (automatic feature / no need to write any thing)
3)General: describe patients appearance such as:
Active, playful OR Sick looking Or irritable in severe distress
4)Neuro: describe mental status/response, any focal sign etc. or write unremarkable if asymptomatic.
5)Head: Free text, can write unremarkable OR chose options applicable to patient’s condition.
6)Eyes: Free text OR chose options applicable to patient’s condition
7)Head: Free text OR chose options applicable to patient’s condition
8)Nose: Free text OR chose options applicable to patient’s condition
9)Throat/Mouth: Free text OR options applicable to patient’s condition
10)Neck: Free text OR chose options applicable to patient’s condition
(Mention adenopathy if any)
11)Chest: Free text OR chose options applicable to patient’s condition
  • Symmetric, asymmetric, pectus (scavatum, carinatum)
  • Retractions if any (subcostal, intercostals, supraclavicular
  • Scars
12)Breast: Free text OR chose options applicable to patient’s condition
13)Lungs: Free text OR chose options applicable to patient’s condition
14)Heart: Free text OR chose options applicable to patient’s condition
15)Abdomen: Free text OR Unremarkable? Chose options applicable to patient’s condition
16)Back: Free text OR Unremarkable? Chose options applicable to patient’s Condition
17)Extremities: Free text OR Unremarkable? Chose options applicable to patient’s Condition
18)Genitalia: Free text OR Unremarkable? Chose options applicable to patient’s Condition
19)Rectal/Prostate: Not done/ deferred or findings
20)Skin: Free text OR chose options applicable to patient’s condition
21)Psychiatry: Free text OR chose options applicable to patient’s condition
22)Comment: Free text.
10.- Reconcile Med / chose options applicable to patient
11. Assessment and Plan:
11. Assessment and Plan: (Continue) / To be written only after attending rounds
  • (THIS IS THE PROBLEM LIST / WORKING DIAGNOSIS /ASSESSMENT AND PROGRES)
  • This should be the summary of the above assessment identifying current problem list: Example:
Hospital Day #
Chronic:
Acute resolved /ing:
New Acute / Active
Example 1:
HD# 3 10 yo with severe developmental delayed, CPMR with seizure disorder (chronic), admitted with breakthrough seizures in status, now controlled on medication (Acute resolved). Aspiration Pneumonia improving on current therapy. (Acute / current Improving)
Example 2:
HD# 2 10 yo with Moderate Persistent asthma, poorly controlled(chronic). Improving from severeexacerbation precipitated by expose to allergens (Acute resolved /ing).
Infected rhinitis, improving.
Food allergy.
OVERALL CONDITION: samples of patient’s conditions:
  • Remains critical unstable OR
  • Improving by still critical
  • Serious, (respiratory failure, severe anemia,) slow improving OR worsening Or intermittent)
  • Guarded (patient is better /stable but still condition may deteriorate)
  • Improving Stable, (this will qualify a patient ready for discharge or transferred to floor.
PLAN:
  1. Level and specifics of need for continuous monitoring
  2. Current therapy: Same or Modify (specify changes). Example: continue current therapy.
  3. Studies to be done and /Or follow
  4. Consults done / recommendation / requested.
  5. Note if above discussed with family.
12. Education: Free text OR chose options applicable to patient’s condition
13. Lever of Service: (can leave blank or chose options. DO NOT WORRY WHICH ONE TO
SELECT, ATTENDING WILL EDITED IT
14. Visit Attending: (attending who discussed case with)
  1. Attending Attest.
  2. Attending Note.
Dr. Alvarez 7/21/06

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