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#ir #peds
Progress Note (Template)
(Service) Progress Note
Date, Time
ID
Age, sex with a history of (non‐active/chronic issues) admitted with (list
active/acute issues for why the patient is admitted). Could also include a
list of recent events that occurred since the most recent note.
SUBJECTIVE
• How was patient overnight, how they feel that day, any new concerns
from the patient/parent
• What has changed since the previous note? Does the patient have any
new symptoms? Any pain? How is the patient coping with the active
symptoms, progression, better/worse.
• Ask the parents and patient’s nurse: behaviour, activity, sleep,
appetite, in and outs.
OBJECTIVE
Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain
I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid
balance
General: what the patient is doing, appearance, behaviour, cognition,
cooperation, disposition
P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it
is common for hospitalized patients to develop problems in these regions.
INVESTIGATIONS
New lab results, imaging or diagnostic tests/ interventions and relevant
results still pending
MEDS
Reviewed daily regarding changes such as new/held/discontinued/
restarted (e.g. Ampicillin day 2/10)
IMPRESSION/ASSESSMENT (IMP)
Summarize what the new findings mean, what progress is being made.
Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/
consult? Differential diagnosis if anything has been ruled in/out?
PLAN (P)
1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day
course required, await urine C&S)
2. Issue (2) 􀃆 plan
3. Issue (3) 􀃆 plan
4. Disposition – plans for home, transfer
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Documentation
egular medications (may not need all; e.g., no need for previous PO antibiotics if starting IV) o Present: what does patient need now o Future: anticipate what patient may need; e.g., fever, nausea, pain, stools <span>Progress Note (Template) (Service) Progress Note Date, Time ID Age, sex with a history of (non‐active/chronic issues) admitted with (list active/acute issues for why the patient is admitted). Could also include a list of recent events that occurred since the most recent note. SUBJECTIVE • How was patient overnight, how they feel that day, any new concerns from the patient/parent • What has changed since the previous note? Does the patient have any new symptoms? Any pain? How is the patient coping with the active symptoms, progression, better/worse. • Ask the parents and patient’s nurse: behaviour, activity, sleep, appetite, in and outs. OBJECTIVE Vitals: HR, BP, RR, SaO2, Temp, daily weight, pain I/O: Inputs (Diet, IVF), Output (U/O, BM/Diarrhea, Vx, Drains), fluid balance General: what the patient is doing, appearance, behaviour, cognition, cooperation, disposition P/E: focused physical exam of system involved plus CVS, RESP, ABDO as it is common for hospitalized patients to develop problems in these regions. INVESTIGATIONS New lab results, imaging or diagnostic tests/ interventions and relevant results still pending MEDS Reviewed daily regarding changes such as new/held/discontinued/ restarted (e.g. Ampicillin day 2/10) IMPRESSION/ASSESSMENT (IMP) Summarize what the new findings mean, what progress is being made. Stable vs. Unstable? Improved vs. Worsened? Waiting investigations/ consult? Differential diagnosis if anything has been ruled in/out? PLAN (P) 1. Issue (1) 􀃆 plan (e.g., UTI on Day 2 of Empiric Abx, likely 14 day course required, await urine C&S) 2. Issue (2) 􀃆 plan 3. Issue (3) 􀃆 plan 4. Disposition – plans for home, transfer Discharge Summary (Template) Check patient’s name, medical record number, date of birth, date of admission, date of discharge, most responsible physician (MRP), ref


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