NormalWriteupGuidelines

AdmitOrders
Thefirstthingyouwilldoforyournewpatient(ADCVAANDIMLS)

Admit:____(service);____(attending);____(resident);____(intern);____(you)
Diagnosis:(brieflyandR/Oisnotadiagnosis)
Condition:good,stable,fair,guarded,critical,serious
Vitals:(usuallyperroutine)alsoq4,qshift,dependsoncondition
Allergies:nkda
Activity:adlib,bedrest,BRP,ambulateq4
Nursing:strictI/O,dailyweightetc.
Alwaysinclude:callhouseofficer:iftemp>101.5(38.0),HR>120or<60,SBP>160or
<90,DBP>100or<50,RR>28or<8
Diet:NPO,clearliquids,regular,1800calorieADA
I/O:generalruleforIVs421.4for1st10kg,2for2nd10kg,1foreachadditional10kg.
50kgpersongets(40+20+3x10=90cc/hr.)Bananabagforalcoholics,etc.
Meds:antibiotics,anticoags,etc.(Ex.
Labs:CBC,Chem7,EKG,CXR,etc.
Special:anythingunusuallikeambulatepatientqshift,etc.
HistoryandPhysical
2ndthingyouwillneedtodoforanypatientyoupickup.Manyofthehospitalswillhaveforms;
youshouldneverleaveanyspacesblank.Weprovidethewaystodescribeeverythingnormal.
CC:____y.o.genderwithhistoryof____,_____,(chronicdz)presentswith(majorsymptom)x
(duration).
HPI:Describesymptom,quality,onset,duration,alleviating,exacerbating,medstaken,course
ofdz.Addassociatedsymptomsandpertinentnegatives.Alwaysaddf/c/n/v/d.Relevantlab
values.Chronological.
PMHx:generalhealth,childhooddzs,adultillnesses(dm,htn,copd).Hospitalizations.
Immunizations.
PSHx:Operationsandroughdates
Allergies:NKDA
OB/GYNHx:lastmenstrualperiod,cyclelength,spotting,flow,etc.
MEDS:canbepartofHPI,butforoldfolkdeservesaspecialplace.Includequantityand
frequency.
SHx:HEADSifyouhavetime.Definitelyincludetobacco,EtOH,drugs,work,andliving
situation.
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FHx:Healthandcauseofdeathofparentsandgrandparents.Siblings.CAD,HTN,HL,DM,etc.
ROS:*mosttimesjustwritedenies....(donthavetodoall)
Gen:usualweight/recentchange.Weakness,fatigue,fever,chills
Skin:rashes,bump,sores,itchingdryness
Head:headache,dizziness,vertigo
Eyes:vision,diplopia,pain,redness,glaucoma,cataracts
Ears:hearing,tinnitus,aches,discharge
Nose:stuffiness,discharge,epistaxis,sinuspain
Throat:sorethroat,hoarseness,dysphagia,bleedinggums
Neck:stiffness,pain,masses
Breasts:lumps,tenderness,nippledischarge,gynecomastia
Lungs:SOB,cough,sputum,hemoptysis,pleuriticpain,wheezes
CV:chestpain,radiation,palpitations,blockscanwalk,orthopnea(#ofpillows),orthostasis
GI:pain,appetite,heartburn,vomiting,stools(diarrhea,color,caliber,blood,constipation)
GU:frequency,urgency,hesitancy,retention,caliber,nocturia,pain,blood,incontinence
Malerepro:libido,erection,discharge,sores,infertility
Femalerepro:libido,discharge,itching,menarche,menses(regularity,frequency,duration,
flow,spotting),menopause,#pregnancies,deliveries,abortions,stillbirths,birthcontrol
Musculoskeletal:pain,swelling,redness,arthritis,gout,backache,weakness,cramps
Neuro:convulsion,tremor,paralysis,incoordination,pain,syncope,vertigo
PhysicalExam
Vitals:(alwaysthefirstpart)
General:WDWN,NAD(obese,wasted,chachetic,sob,etc.)A+Ox4.
Skin:Unremarkable(includesize,location,symmetry,descriptionoflesions)
HEENT:NCAT
Eyes:PERRLA,EOMI,conjunctivaclear,anicteric
Ears:tympanicmembranesclear,visiblelightreflex,noerythema,nodischarge,noeffusion
Nose:noerythema,nodischarge,narespatent
Throat:oropharynxclear,noerythema,noexudate,moistmucousmembranes,tonsilspresent
Neck:supple,noLAD,noJVD,nomasses
Chest:CTAb,norales,ronchi,wheezes
CV:RRRnom/r/g
Abd:nontender,nondistended(NT/ND),+bs,nomasses,noHSM
GU:(alwaysexamine)neglesions,neghernia,nomasses,noLAD
Rectum:(always)goodsphinctertone,nohemorrhoids,nomasses,prostatenormalno
masses,guaiacneg.
Ext:2+peripheralpulsesbilaterally,nopedaledema,noC/C/E
Neuro:+Ox4,2+DTRs,downgoingBabinski,neg.Romberg,goodfingertonose,5/5motor
Sensoryintact,gait,tone,musclebulk.CNIIXIIgrosslyintact.
LabsandStudies
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AssessmentandPlan:Problembased.ThemostimportantpartofH&P.
Problem1:(examplechestpain,alwaysthepresentingproblem)
1.Mostlikelycausedby.(andwhy)
2.Differential
3.Plan(bothworkupandtreatment)
Problem2:(otherproblemsnotedonphysicalexam,labs,studies)
ProgressNotes
Youwilldooneeveryday.ThesearerelativelybriefinSOAPformat.Focusontheproblem.
(Title)Date/TimeMSIIIProgressNote
S:HD#____for____y.o.M/Fwithhxof___,____,admittedfor____(currentdiagnosis).
Overnight...
Describehowpatientfeels,slept.Includelastbowelmovement(caliber,blood,etc.),urination
Deniesf/c/n/v/d
Meds:alwaysincludecurrentmeds,recentd/cmeds,orchanges
O:Vitals:Tm@,Tc,BP,P,R,Sat,I/O
+minimalphysicalexam,focusonrelevantpartsfordz
Gen:WDWN,NAD
HEENT:moistmucousmembranes
Neck:supple,lad,jvd
Lungs:CTAb,norales,ronchi,wheezes
CV:RRRnom/r/g
Abd:NTND,+bs,noHSM
Ext:neg.C/C/E(cyanosis,clubbing,edema)
Labs:canwritepending,butthenhavetoincludeaddendumlater.
Alwaysgoodtoincluderesultsfromimagingstudies.
Forextrabrowniepoints,summarizenotesandrecommendationsfromconsults
A/P:goodtodobysystem,especiallyininternalmedicine
Neuro:stateproblemthenyourplan
CV:stable,noissues(goodtowritewhennothinggoingon)
Pulm,GI,GU,FEN,ID,Heme/onc(includethesealso)
DischargeOrders
Dischargetohome
Condition:
Activity:astolerated,adlib,physicaltherapy
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Lines:d/c(includeallcurrentlines)
Diet:regular(lowcholesterol,ada1800,lowsaltetc.)
Meds:(probablylongestincludeallmedsgoinghomeon,glucosestrips,etc.)
F/U:usuallywriteinonewithPCP
Specialinstructions:ifunusual.
Presentations
Threetypes,thereisacertainelitisminmemorizing,trynottoreadthemwordforword.
Formal:prettymuchyourh&p.Yourgoalistoconvinceyouraudience,sothatyour
assessmentshouldnotsurpriseanyone.Althoughawellorganizedh&pisimportant,
intheendhavingasoundassessmentandplanismostimportant.Goodtohavea
differentialwithgoodreasonswhysomearestrongerthanothers.
SOAP:Thesearefordailyrounds,tocatchupresident/attendingwithpatient,againA/Pis
important.
PrettymuchpresentingyourSOAPnote.
Bullet:Thisisaonesentencetofamiliarizepatient:HD#,hxof,diagnosis,currentcondition,
whatisbeingdone.
Orders
Youwillalwaysimpressinternsbyhavingtheordersalreadywrittenoutsoalltheyhavetodois
signthem,ofcoursethisimpliesyouhaveacluewhattodo,whichcanalwaysbeamystery.
Everythingthatneedstobedoneneedstobewritteninorders.
Commonorder:MLabs:CBC,chem7
Abx:4thingsalwaystobeincluded:name,quantity,modeofentry,
frequency
Lisinopril10mgPOqd