Acute Care
Acute Care
Acute Care
Hospitalist (In-patient)
Templates developed through PQI and engagement with the hospitalist team at Vernon Jubilee Hospital.
History and Physical
HOSPITALIST ADMISSION NOTE
[Insert Hospital]
ID: []
Referred by: []
REASON FOR ADMISSION:
[]
HISTORY OF PRESENTING ILLNESS:
[]
GOALS OF CARE:
[]
PAST MEDICAL HISTORY:
[]
PAST SURGICAL HISTORY:
[]
ALLERGIES:
[]
HOME MEDICATIONS:
[]
SOCIAL HISTORY:
[]
IMMUNIZATIONS:
[Up to date]
FAMILY HISTORY:
[None relevant]
EXAMINATION:
Vitals: []
General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I – XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]
SPECIAL INVESTIGATIONS:
[]
ASSESSMENT & PLAN:
[]
DISPOSITION:
Admit to VJH Hospitalist
VTE: []
Diet: []
MOST: [If you made any changes or had discussions, leave out if captured in above section]
Consults: [PT, OT, TL, SW etc]
EDD: []
Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.
The PEN Project
Progress Note
HOSPITALIST PROGRESS NOTE
[Insert Hospital]
MOST []
SUMMARY:
[80-year-old female admitted with CHF.]
TODAY:
[Capture SOAP elements reflecting changes in patient’s condition, reasons for change of treatment and outcome of treatment]
Plan:
[List today’s plan]
ACTIVE ISSUES:
[Problem list]
BARRIERS:
[]
PMH:
[]
This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.
The PEN Project
Discharge Summary
HOSPITALIST DISCHARGE SUMMARY
Vernon Jubilee Hospital
MOST []
DATE OF ADMISSION: []
DATE OF DISCHARGE: []
DESTINATION: []
PRIMARY DIAGNOSIS:
[]
SECONDARY DIAGNOSIS:
[]
CONSULTATIONS:
[]
PROCEDURES:
[None]
PAST MEDICAL HISTORY:
[Import from progress note and ensure updated with new findings]
DISCHARGE MEDICATIONS:
[]
SUMMARY OF ADMISSION:
[Provide a one paragraph summary, can import summary and just add information]
FOLLOW UP AND RECOMMENDATIONS:
1. [Recommended follow up labs, imaging etc ]
2. [Results pending at time of discharge]
3. [Referrals submitted while in hospital ]
Thank you for involving the hospitalist service. This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me.
The PEN Project
Consultation
HOSPITALIST CONSULTATION NOTE
[Insert Hospital]
REFERRED BY: []
ID: []
REASON FOR REFERRAL:
[Reason for referral]
HISTORY OF PRESENTING ILLNESS:
[Provide more information about complaint, focusing on symptoms and events leading up to admission. Also incorporate collateral information]
GOALS OF CARE:
MOST [current MOST status]
PAST MEDICAL HISTORY:
[]
PAST SURGICAL HISTORY:
[]
ALLERGIES:
[]
HOME MEDICATIONS:
[]
SOCIAL HISTORY:
ADL: []
Living Conditions: []
Support: []
Family: []
Substances: []
Alcohol: []
Occupation: []
Drivers License: [yes]
Marital Status: []
IMMUNIZATIONS:
[]
FAMILY HISTORY:
[None relevant]
EXAMINATION:
Vitals: []
General: [Appears well, no pallor, no jaundice, no peripheral edema, no clubbing, no signs of dehydration, skin is normal]
HEENT: [NAD]
Chest: [clear with GAEB, no adventitious sounds]
CVS: [peripheral pulses are present pulse is regular, JVP is normal, S1 S2 = normal, no murmurs]
Abdomen: [No distension, no tenderness on palpation, no hepatomegaly or splenomegaly clinically, bowel sounds are present, no hernias]
Neurology: [orientated x 3, PEARL, No nystagmus, Finger-nose test is normal, heel to shin test is normal, no gaze palsy, CN I – XII roughly intact, power 5/5 throughout, reflexes are normal, Babinski is negative, no neck stiffness]
Musculo-skeletal: [NAD]
SPECIAL INVESTIGATIONS:
[]
IMPRESSION:
[Generate a problem statement that can be carried over to the progress note. This is a summary of the problems identified.]
ASSESSMENT & PLAN:
1. []
Thank you for involving the hospitalist service. This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.
The PEN Project
Social History
ADL: []
Living Conditions: []
Support: []
Family: []
Substances: []
Alcohol: []
Occupation: []
Drivers License: [yes]
Marital Status: []
The PEN Project
SOAP (Adjusted)
HOSPITALIST PROGRESS NOTE
[Insert Hospital]
SUMMARY:
[80-year-old female admitted with urosepsis]
Subjective:
[]
Objective:
[]
Assessment:
[]
Plan:
[]
BARRIERS/VTE/EDD:
Barriers: []
VTE: []
EDD: []
This document was created using voice recognition software and as a result might contain some errors. If anything is not clear, please do not hesitate to contact me.
The PEN Project
Transfer Summary
HOSPITAL TRANSFER SUMMARY
Date of admission: []
Date of transfer: []
Discharge disposition: []
Accepting physician: []
MOST []
Admission diagnosis:
[Main reason for admission]
Secondary Diagnosis:
[All diagnoses during the admission]
Past Medical History:
[Medical history]
Specialist Consults During Admission:
[Name, date, specialty]
Interventions:
[Angiogram Date: ]
[Biopsy: Date & Site]
[Blood Products: dates]
[Cardioversion: Date ]
[CPR: Date]
[Catheter: Date (removed on )]
[Central Lines: Date (removed on )]
[Chest Tube: Date (removed on )]
[Dialysis: Date ]
[Drains: Date and Site]
[Endoscopy: Date and by whom with findings]
[Feeding Tube: Date (removed on )]
[Mechanical Ventilation/BiPAP, CPAP: Date ]
[NG Fees: Date ]
[Pacemaker: Date ]
[Pleurocentesis: Date & findings]
[Paracentesis: Date & findings]
[Radiation: Date ]
[Chemotherapy: Date ]
[Tracheotomy: Date ]
[TPN: Date ]
[Vac Dressing: Date ]
Operative Interventions:
[]
Pertinent Investigations:
[]
Current Medications:
[]
Social Issues:
[]
Summary:
[]
Thank you for involving the hospitalist service. This note was created with voice recognition software and may contain some errors. If anything is unclear, please do not hesitate to contact me.
Dr. Stephanie Houde
Purpose of Documentation
Observe, record, tabulate, communicate.
- The primary purpose of clinical documentation should be to support patient care and improve clinical outcomes through enhanced communication
- Physicians working with their care delivery organizations, medical societies, and others should define professional standards regarding clinical documentation practices throughout their organizations. Further, clinical usefulness of health information exchange will be facilitated by appropriate redesign of clinical documentation based on consensus-driven professional standards unique to individual specialties as a result of collaboration with standards-setting organizations.
- The clinical record should include the patient’s story in as much detail as is required to retell the story.
- When used appropriately, macros and templates may be valuable in improving the completeness and efficiency of documentation, particularly where that documentation is primarily limited to standardized terminology, such as the review of systems and physical examination findings.
- The EHR should facilitate thoughtful review of previously documented clinical information. Ready review of prior relevant information, such as longitudinal history and care plans as well as prior physical examination findings, may be valuable in improving the completeness of documentation as well as establishing context.
- Where previously documented clinical information is still accurate and adds to the value of current documentation, this process of “review/edit and/or attest, and then copy/forward” (hereafter referred to as copy/forward) of specific prior history or findings may improve the accuracy, completeness, and efficiency of documentation. However, these documentation techniques can also be misused, to the detriment of accuracy, high-quality care, and patient safety.
- Effective and ongoing EHR documentation training of clinical personnel should be an ongoing process.
- As value-based care and accountable care models grow, the primary purpose of the EHR should remain the facilitation of seamless patient care to improve outcomes while contributing to data collection that supports necessary analyses.
- Structured data should be captured only where they are useful in care delivery or essential for quality assessment or reporting.
- Patient access to progress notes, as well as the rest of their medical records, may offer a way to improve both patient engagement and quality of care.
SUMMARY
Annuals of Internal Medicine
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