University Of Miami Infectious Diseases Progress Note

ADVERTISEMENT

1
UNIVERSITY OF MIAMI INFECTIOUS DISEASES
Progress Note
Date:
Patient Name – Room Number:
___________________________________________________________________
Subjective:__________________________________________________
-Problem List:
___________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Vital Signs
See Computer Medical Records
T Current =_________________ TMax =__________________________________
RR = ________HR=__________ O2 saturation = ___________________________
Blood Pressure =_____________ Mean BP =_______________________________
Intubated:
Yes / No
-Allergies:
If intubated, Ventilator Settings:___________________________________________
Today’s ABG:
I/O: ___________ / ___________ 24 hours fluid balance: _____________ ml
Urine output _____________
-Central Lines Status:
MIVF:
Date of Line:
Renal Replacement Therapy: None /
HD /
CVVHD /
UF
Physical Exam:
General: AOx3: Yes / No
NAD: LAN =Yes / No,
Other:
Neurological
Mental Status: Alert / Somnolent / Obtunded / Sedated
Oriented: Y / N
-Medications: SEE MAR
HEENT: PEARL: Yes / No,
EOMI: Yes / No
Antimicrobials: (# DAYS)
Neck: Supple: Yes / No,
JVD = Yes / No,
Bruits: Yes / No
LAN =Yes / No,
Respiratory
Adequate Inspiratory Effort = Yes / No
BS: Clear to Auscultation
Wheezing: Left
Right
, Ronchi
, Fremitus:
Other:
Cardiovascular -
RRR = Yes / No
S3=
Yes / No
S4=
Yes / No
Murmurs Yes/ No
Rubs Yes/ No
Abdominal Exam
Bowel Sounds Present = Yes / No
Abdominal Tenderness= Yes / No
Abdomina Distention = Yes / No
Rebound =
Yes / No
Extremities:
Pulses present = Yes / No
Clubbing: Yes
/ No,
Lower extremity edema = Yes / No
Skin: Rashes = Yes / No
Other:
Fellow Signature:
__________________________
_______
Attending Physician Signature:
_______________
Patient seen and examined between Attending Physician and Training Physician
Case discussed between Attending Physician and Training Physician

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Go
Page of 2