Fillable Thoracic & Cardiovascular Critical Care Progress Note Template (Page 2 of 2) in pdf

Thoracic & Cardiovascular Critical Care Progress Note Template Page 2

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E/M

THORACIC & CARDIOVASCULAR CRITICAL CARE

Level

Patient Identification

PROGRESS NOTE

DO NOT USE THE FOLLOWING ABBREVIATIONS

Q.D. – write daily / u – write unit / Q.O.D. – write every other day / I.U. – write International Units

MS or MSO

– write Morphine Sulfate / MgSo

– write Magnesium Sulfate

Avoid trailing zero (e.g. 5.0 mg) / Use a leading zero (e.g. 0.5 mg)

Pg 2 of 2

Assessment, Plan & Treatments (please document diagnosis with treatments):

Labs

Neuro/Psych

Phosphorus

Lactate

Bilirubin

Alk. Phosphate

AST (SGOT)

ALT (SGPT)

Pulm

Protein, Tot.

Albumin

Renal

Protime

INR

APTT

Other:

GI/Nutrition

ABG:

SVO

Infectious Disease

Endocrine

Critical Care

VAP precautions

Sedation vacation

GI prophylaxis

Heme

DVT prophylaxis

Restraint orders

Nutritional needs addressed

Foley addressed

Line removal addressed

Family updated

Signature:

Pager

Date

Time

Teaching Physician Documentation

Critical Care Time: My direct critical care time was

Minutes. The time documented above was spent providing direct care to this critically ill patient does not include any

time for Procedures. Furthermore, in calculating this total time I have been careful to only include the minimum time during which I personally was providing the critical care services

listed to this patient while I was on the unit or floor.

I examined and evaluated the patient and agree with the resident’s/non-physician provider’s findings and plan as documented, except:

Dictated Job #:

99231

99232

99233

99291

99292 X

MR Form S8092-107

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