Notes

Orders

Dictations

Admission H&P

Date/Time/Name/Age

CC: One sentence of the patient's cc

HPI: NLDOCAT (This is a __y.o. ___ Caucasian /AA M/F with PMH of _______ presented with c/o _______ in R/L foot/leg (specify the location) with ______(kind of pain) which started ______d/hr ago secondary to ______. Aggravating factor, course of cc, treatment rendered so far). Hx/mechanism of trauma if trauma case. Previous physicians seen.

PMH:

PSH:

MEDS:

ALL:

SH:

FH:

Immunization hx

Last CXR, pop smear, PPD, EKG

ROS: HEENT, CV, Resp, GU, GI, M/S, dermatological, neuro, vasc,

DNR status:

Vitals: Temp, HR, RR, BP, orthostatic, O2 sat.

PE: general appearance, head, nose/ear, neck, CV, chest, abd, peripheral vasc, neuro, skin, rectal, genital, extremities, cranial nerves, M/S, cerebellar, gait, Radiographic exam, labs

Impression: All the medical conditions including non-podiatric

Plan: for each impression (consultation, followed by medicine, followed by podiatry, sx plan, d/c plan). Include: Casting, injection, DSG, Xrays, Rx (including dosage), ABX administered, WB status, nails/HK lesions debrided, labs/micro ordered, close reduction, debridement of the wound, irrigation, primary closure

D/W Drs._____ and _____ (medicine co-admitting attending and podiatry attending)

Sign/print last name/pager #

Daily SOAP note

Date/Time/Hospital day #/Postoperative day #/List of ABX the patient is on and each day # (in the margin)

Subjective - The patient is seen at bedside doing well/resting comfortably/feeling better/still c/o N/V/F/C/NS/CP/SOB/HA/D. Calf pain? Thigh pain? Appetite? Void? BM? List of complaints.

Objective -

VS: Tmax, Temp, Pulse, Resp. rate, BP

DSG C/D/I? Strikethrough (+ to which layer of DSG)? SCD in place? Ice in place? Foot elevated?
Vascular: pedal pulses PT/DP __/4 if any changes, CFT, digital hair, sign of compartment syndrome, lymphangitis, edema (pitting/non-pitting), lymphadenopathy, erythema, ecchymosis, sign of DVT, varicosity, temperature gradient
Neurological: (if any changes): Vibratory, light touch, sharp/dull, temp, proprioceptive sensations, Babinski sign? Clonus?
Dermatological: open lesions? Skin line? Fx blister? Ulcer description? (changes in size, depth, odor, drainage, purulence, probing, border, base) Color? Turgor? Texture? Hyper/hypopigmentation? Epidermolysis? Fluctuant?
Musculoskeletal: Pain on palpation/ROM/compression/distraction, pertinent negatives, ROMs, gross deformity, amputated parts
Micro: Gram stain result, culture result
Xrays: fx description if trauma case (direction/location of the fx, displacement, angulation, rotation, comminution, intra/extra articular), periosteal reaction, bone resorption, degenerative changes, FB, gas in tissue, calcified vessels. Compare to previous Xrays if it's a serial xray.
Labs: New results of CBC with D, BMP, CRP, ESR, Ha1c, UA, EKG, CXR, Tox screen, ETOH level when they come back
Vascular study: TCOM, PVR, angiogram results if done
Other studies including non-podiatric studies such as echo cardiogram, stress test, and so on.
*Note that you have reviewed previous notes from other attendings, consults, etc

Assesment - _________R/L foot/ankle/leg (specify the location) secondary to _______--stable/unstable/improving/good post-operative progress. And list all the other conditions.

Plan - DSG change regimen, Xrays, Rx (including dosage), continue ABX?, WB status, Sx plan, D/C plan, labs/micro ordered, debridement of the wound, irrigation, F/U plan, issues d/w the patient such as prognosis and future plans, consultations. D/W Dr._____ and Pod team (and other services.)

Sign/print last name/pager #

Standard Consult

Date/Time/Attending Dr's name/Reason for consult

Subjective - This is a __y.o. ___M/F with PMH of _______ presented with c/o _______ in R/L foot/leg (specify the location) with ______(kind of pain) which started ______d/hr ago secondary to ______. Cover NLDOCAT. If trauma, hx/mechanism of trauma.If infection, list his/her constitutional symptoms.

Social issues such as drug abuse should be emphasized,

PMH:
PSH:
MEDS:
ALL:
SH: ETOH, tobacco, illicit drugs, home situation, family
FH: Mother, Father, other relatives. Are they alive or deceased?
ROS:

Objective - Temp, Pulse, Resp. rate, BP

General appearance: AO x 3? Build? Articulation?
Vasc: pedal pulses PT/DP __/4 (if not palpable, Dopplerable?), CFT, digital hair, sign of compartment syndrome, lymphangitis, edema (pitting/non-pitting), lymphadenopathy, erythema, ecchymosis, sign of DVT, varicosity
Neuro: Vibratory, light touch, sharp/dull, temp, proprioceptive sensations, MMT __/5, DTR __/4, Babinski sign? Clonus?
Derm: open lesions? Skin line? Fx blister? Ulcer description? (size, depth, odor, drainage, purulence, probing, border, base) Color? Turgor? Texture? Hyper/hypopigmentation? Dystrophic nails? HK lesions? Exfoliation? Fluctuant?
M/S: Pain on palpation/ROM/compression/distraction, pertinent negatives, ROMs, gross deformity, amputated parts
Xrays: fx description (direction/location of the fx, displacement, angulation, rotation, comminution, intra/extra articular, complete/incomplete), periosteal reaction, bone resorption, degenerative changes, FB, gas in tissue, calcified vessels
Labs: CBC with D, CMP, CRP, ESR, Ha1c, UA, EKG, CXR, Tox screen, ETOH level according to the patient
Other tests: MRI/CT etc

Assesment - _________R/L foot/ankle/leg (specify the location secondary to _______--stable/unstable.

Plan

Casting
injection
DSG
Xrays
Rx (including dosage)
ABX administered
WB status
Sx plan
labs/micro ordered
close reduction
debridement of the wound
irrigation
primary closure
F/U plan
admission
D/W Dr._____ and Pod team

Sign/print last name/pager

Standard Consult

pt name
MR#
Attending physician
Date of admit
Date of discharge
Age
Admit Dx
CC and HPI
Physical findings (read off H & P)
Lab values
Hospital course including: consults, and sx procedures
Condition at D/C, disposition
Discharge meds
Follow-up date
Final Dx
Copies to be sent to....

.

Important note inclusions:

Summary:
IV ABX, IV PAIN MNGT,DRAIN MNGT,PT
Procedures:
IV PAIN MEDS,IV ABX,DVT PROPHYLAXIS, FOLEY, SURGERY