Sjh Daily Progress Note Siu School Of Medicine

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ST. JOHN’S HOSPITAL
800 E. Carpenter St.
Springfield, Illinois 62769
Date: _______________________________________________ Time: ______________________________________________
CHIEF COMPLAINT: ______________________________________________________________________________________
ATTENDING NOTE:
INTERVAL HISTORY:
£ See assessment & plan
CC:
History:
(4 aspects for level 2 or level 3) or
£ 3 chronic conditions addressed
£ unobtainable
REVIEW OF SYMPTOMS:
MEDS: £ Reviewed MAR
£ Past medical social, family histories reviewed as
documented previously (for level 3) £ In addition
ROS:
(1 finding for 1 system = level 2; 1 finding for
AM
NOON
PM
NIGHT
2 systems = level 3)
Accuchecks (time) :
£ I interviewed the patient and agree as documented
£ Corrections made £ In addition
Blood sugar value:
EXAM:
(2 findings for 1 system = level 1; 3 systems
VITAL SIGNS:
= level 2; 6 systems = level 3)
Temp Resp
Heart
Blood pressure
Weight
Ins / Out
Pulse O
£ I examined the patient and agree as documented
2
Rate
Rate
% O
2
£ Corrections made £ In addition
KEY FINDINGS:
£ Foley catheter £ NG tube £ Central line:
£ Drains £ IVF £ Tele
EXAMINATION:
£ Medical data: I reviewed including as documented
MEDICAL DATA:
on this form and:
£ Prior information
£ Consultation notes
Na
CI
Bun
Hb
£ ECG
£ Prior ECG
Glucose
wbc
Platelets
K
HCO
Cr
Hct
£ Radiology images
£ Prior Radiology images
3
Initials: _________________________
Initials: _________________________
GENERAL MEDICINE UNIT - DAILY PROGRESS NOTE
#8875 (R 12/06)
(Medical Staff Records)
(1 of 2)

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