Page 63 - Radiology Book

List ABX: (all antibiotics, Day #)
List Pressors:
Other: (may include steroids/blood thinners, nutrition/IVFs) Lines: (Location, Day #)
· Forms, Forms, Forms! (Did you hear that internists have a
lot of paperwork?) -Code Status, Transfusions, Insulin Sliding Scale, Restraints, etc. Make sure these are signed each day as appropriate.
· Only order what you are comfortable ordering (any doubts/questions-ask your Senior resident)
· Remember your AM labs for tomorrow
· Discharge Planning:
1. For home health and placement: call Social Workers and Care Coordinators, order PT/OT. Do this as early as possible.
2. If pt needs procedure prior to DC (i.e. PICC, stress test), order early.
3. Get DC Meds done early, or you’ll be scrambling at the last minute.
daily Progress note
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S:
Any acute events. Talk with the nurse (they know the patients). Report any changes (pressors, intubation/extubation, ABX-started/stopped). Note any consultant’s comments, patient/family concerns etc.
O:
· Vital Signs and ranges (including Tc and Tmax)
· Vent Settings (mode, TV, PS, Peep, FIO2, location of ETT)
PE:
Bare minimum- HEENT (look at eyes), heart, lungs, abdomen, peripheral pulses (esp if on pressors), and check all line sites. Labs/Imaging: List all of them. Go back to date of admission and report all culture data. Be prepared to explain all abnormal
labs (ask your Senior resident if you’re not sure why an abnormality is present)
A/P:
· Problem-Based (not System-Based as you may have been taught in medical school). Use the Attending’s note from the previous day to determine which problems they thought were pertinent.
· DO NOT BE AFRAID to write down your thought processes and commit yourself to DX and Plan (run it by your Senior resident before you decide to order a thoracotomy, amputation etc...just kidding)
· The end of every note should include comments on F/E/N, GI /DVT PPx, and code status
Extra items to address each morning:
Progress Note