Thoracic & Cardiovascular Critical Care Progress Note Template
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2This form is for use with hospital patients only.
This form is for use with hospital patients only.
E/M
THORACIC & CARDIOVASCULAR CRITICAL CARE
THORACIC & CARDIOVASCULAR CRITICAL CARE
Level
Patient Identification
PROGRESS NOTE
PROGRESS NOTE
DO NOT USE THE FOLLOWING ABBREVIATIONS
DO NOT USE THE FOLLOWING ABBREVIATIONS
Q.D. – write daily / u – write unit / Q.O.D. – write every other day / I.U.
write every other day / I.U. – write International Units
MS or MSO
– write Morphine Sulfate / MgSo
write Morphine Sulfate / MgSo
– write Magnesium Sulfate
4
4
Avoid trailing zero (e.g. 5.0 mg) / Use
a leading zero (e.g. 0.5 mg)
Operation(s):
Postoperative day:
INTERVAL HISTORY:
NEED 4 ELEMENTS FOR HIGHER LEVEL (HPI
NEED 4 ELEMENTS FOR HIGHER LEVEL (HPI – Location, Timing, Duration, Context, Modifying Factors, Severity, Associated Symptoms)
Location, Timing, Duration, Context, Modifying Factors, Severity, Associated Symptoms)
Events in past 24 hrs:
General Appearance:
Neuro:
Brief assessment of mental status:
Exam:
Drips & Meds
Fentanyl
Other:
Cardiac: Heart rate:
Rhythm: Sinus
A. fib
A. flutter
Junctional
Other:
Pacing:
Systemic BP:
/
CVP:
Epinephrine
Co/Cl :
Pap:
/
PCWP:
/
SVR:
Milrinone
ECG viewed & interpreted by me.
Dobutamine
Dopamine
Cardiac/Vascular Exam:
Vasopressin
Norepinephrine
Amiodarone
Cardiac Mechanical Support:(VADS/IABP)
Metoprolol
Pulmonary:
Nasal cannula:
Mask:
Mask:
Respiratory rate:
Secretions:
Statin
Mechanical ventilation
NIPPV:
BIPAP:
/
CPAP:
ACE I
Mode:
CMV
SIMV
PCV
APRV
Other:
Aspirin
Settings: Set/Spont. rate:
/
Tidal volume:
Tidal volume:
PEEP
PS
FIO
2
Chest Tubes
Mediastinals:
Pleural Tubes:
Chest x-ray viewed & interpreted by me.
Albuterol
Other:
Exam:
Pulmonary-Mechanical Support(ECMO):
Renal: I/O (24/8) hrs:
/
CRRT
HD
Net fluid removal:
Lasix
Exam:
Other:
GI/Nutrition:
NG tube
24hr drainage
NPO
NPO
Enteral
NGT
SBFT
Type:
Lansoprazole
Rate:
Goal:
Ranitidine
Parenteral:
PPN
TPN
Bowel movement:
Bowel movement:
Bowel sounds: present / absent
Bowel sounds: present / absent
Pantoprazole
Exam:
Esomeprazole
Infectious Disease:
Tmax:
Tubes & lines (lineday/siteday)
lines (lineday/siteday)
Antibiotics (day#/Total)
Cultures:
Heme/Lymph:
Warfarin
Heparin
Endocrine:
Glytec
ICU Insulin Protocol
Skin Exam:
Insulin Sliding Protocol
HEENT:
Musculoskeletal:
MR Form S8092-107
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