Do I have to document that?. Pam Shaw MD. Documentation. Hospital H&P Daily Notes Procedure Notes Discharge Summary Off-service Notes Orders Consults. History and Physical Format. History. Physical exam. Vital signs General HEENT Lungs CV Abdomen Musculoskeletal Neuro
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Do I have to document that?
Pam Shaw MD
Assessment or Problem list
Hospital Day # 3
Day # 3 Ceftriaxone, 1g IV BID
PE: No JVDLungs: Crackles and dullness to percussion at Right base with egophony; no change consistent with yesterday C/V: RRR without murmurAbd: soft, non-tender , positive BSExt: no edema
Labs: Sputum and blood cx still negative; otherwise no new data
1) Pneumonia: Right LL pneumonia. Responding to IV Ceftriaxone, with decreasing O2 requirement and fever curve. Also feeling better. No evidence of complications. Plan:
consider discharge in approximately 2 days if continues to improve
Specific concerns that the patient may have (e.g. patient initiated discussion about the role of cancer screening test, cholesterol measurement, etc).
Plan # 2:
For men this would include