MCV Hospitals and Physicians VCU Health System Richmond, Virginia 23298 PATIENT PROGRESS NOTES

Internal Medicine Attending Physician Daily Progress Note

Date: ___________ Time: _________

I have interviewed & examined the patient, & confirmed and agree with the history, examination, assessment & plan of Dr. ____________________________. HISTORY:

ROS (

if done, circle abnormal)

___ Muscle - pain, weakness ___ Breast - pain, abscess, mass, discharge ___ Neuro - weakness, paralysis, memory, insomnia ___ Psych - fatigue, insomnia, mood, depression, crying ___ Endocrine - polyuria, polydypsia, cold/heat intolerance ___ Heme petechiae, ecchymosis, easy bruisability ___ Skin rash, tattoos, scars, edema

___ General weight loss, fevers, chills, night sweats ___ Eyes - poor vision, pain ___ ENT - sore throat, pain, runny nose, dysphagia ___ CV - pain, palpitations, hypo/hypertension ___ Resp - dyspnea, cough, tachypnea, wheezing ___ GI - pain, nausea, vomiting, diarrhea, constipation ___ GU - pain, bleeding, incontinent, nocturia, smell

EXAM Area VS/Gen. Eyes ENT/ Neck/ Breast

CV

Lungs GI

GU Musculoskeletal Skin Neuro Psych

Lymphatic

Element ______P, _________BP, ____R, ______T, __General __Conjunctivae, lids, pupils & irises __ Fundoscopic __Ears & nose, external canals & TMs __Nasal mucosa, septum & turbinate __Lips, gums, teeth __Oropharynx, oral mucosa, salivary glands __Hard & soft palates, tongue, tonsils & post. pharynx __Thyroid __Neck __Breasts & axillae __Palpation & auscultation of heart __Carotid art. __Abd aorta __Fem art. __Pedal pulses __Extremities for edema &/or varicosities __Resp effort __Percussion & auscultation of lung __Abdomen - note presence of masses or tenderness __Liver & spleen __Anus, perineum, rectum, sphincter tone, FOBT __Scrotal contents __Penis __Prostate __Gait & station __Digits, nails __Joints, bones, muscles __ROM, Stability __Palpate skin (edema) & SQ tissue __Cranial nerves __ Strength & tone __DTRs __Sensation __Cerebellum __Judgment & insight __Mood & affect __Orientation to time place, person __Recent & remote memory __Lymph nodes in 2 or more areas

Results (

alone = normal, if abnormal write results)

Internal Medicine Attending Physician Daily Progress Note (continued)

TESTS REVIEWED __CBC __Chemistry __Chest x-ray __CT scans __Cultures __Other _______________ MANAGEMENT OPTIONS __Drug changes __Surgery planned __IV fluids __Transfusion __IV antibiotics __Other:

ASSESSMENT:

Current Medications

Problem: 1.

Plan:

2.

3.

4.

5.

6. Disposition/Discharge Planning

___________________________________________________ .

______________ Level of service