Post on 03-May-2018
MR Form S8092-107
This form is for use with hospital patients only.
THORACIC & CARDIOVASCULAR CRITICAL CAREPROGRESS NOTE
DO NOT USE THE FOLLOWING ABBREVIATIONSQ.D. – write daily / u – write unit / Q.O.D. – write every other day / I.U.
MS or MSO4 – write Morphine Sulfate / MgSoAvoid trailing zero (e.g. 5.0 mg) / Use
Operation(s):
INTERVAL HISTORY: NEED 4 ELEMENTS FOR HIGHER LEVEL (HPI
Events in past 24 hrs:
General Appearance:
Neuro: Brief assessment of mental status:Exam:
Cardiac: Heart rate: Rhythm: Sinus
Pacing:
Pap: / PCWP:ECG viewed & interpreted by me.
Cardiac/Vascular Exam:
Cardiac Mechanical Support:(VADS/IABP)Pulmonary: Nasal cannula: Mask:
Mechanical ventilation NIPPV: BIPAP:Mode: CMV SIMV PCV APRV Other:
Settings: Set/Spont. rate: / Tidal volume:Chest Tubes Mediastinals:
Chest x-ray viewed & interpreted by me.
Exam:
Pulmonary-Mechanical Support(ECMO):Renal: I/O (24/8) hrs: / CRRT
Exam:
GI/Nutrition: NG tube 24hr drainage NPORate: Goal:
Parenteral: PPN TPN Bowel movement:
Exam:
Infectious Disease:Cultures:
Heme/Lymph:
Endocrine:
Skin Exam:
HEENT:
Musculoskeletal:
This form is for use with hospital patients only.E/M
LevelTHORACIC & CARDIOVASCULAR CRITICAL CAREPROGRESS NOTE
DO NOT USE THE FOLLOWING ABBREVIATIONSwrite every other day / I.U. – write International Units
write Morphine Sulfate / MgSo4 – write Magnesium Sulfatea leading zero (e.g. 0.5 mg)
NEED 4 ELEMENTS FOR HIGHER LEVEL (HPI – Location, Timing, Duration, Context, Modifying Factors, Severity, Associated Symptoms)
A. fib A. flutter Junctional Other:
Systemic BP: / CVP:
Co/Cl : / SVR:
Mask: Respiratory rate: Secretions:
/ CPAP:
Tidal volume: PEEP PS FIO2
Pleural Tubes:
HD Net fluid removal:
NPO Enteral NGT SBFT Type:
Bowel movement: Bowel sounds: present / absent
Tmax: Tubes & lines (lineday/siteday)
Page 1 of 2
Patient Identification
Postoperative day:
Location, Timing, Duration, Context, Modifying Factors, Severity, Associated Symptoms)
Drips & Meds
Fentanyl
Other:
Epinephrine
MilrinoneDobutamineDopamine
Vasopressin
NorepinephrineAmiodarone
MetoprololStatin
ACE IAspirin
AlbuterolOther:
Lasix
Other:
LansoprazoleRanitidine
Bowel sounds: present / absent Pantoprazole
Esomeprazole
lines (lineday/siteday) Antibiotics (day#/Total)
Warfarin
Heparin
Glytec
ICU Insulin Protocol
Insulin Sliding Protocol
MR Form S8092-107 Page 2 of 2
This form is for use with hospital patients only.E/M
LevelPatient IdentificationTHORACIC & CARDIOVASCULAR CRITICAL CARE
PROGRESS NOTEDO NOT USE THE FOLLOWING ABBREVIATIONS
Q.D. – write daily / u – write unit / Q.O.D. – write every other day / I.U. – write International UnitsMS or MSO4 – write Morphine Sulfate / MgSo4 – 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): LabsNeuro/Psych Phosphorus
MgLactate
CV
CaBilirubin
Alk. PhosphateAST (SGOT)ALT (SGPT)
Pulm Protein, Tot.Albumin
RenalProtimeINRAPTTOther:
GI/Nutrition
ABG:
/ / / /
SVO2:Infectious Disease
Endocrine
Critical CareVAP precautions Y N
Sedation vacation Y NGI prophylaxis Y N
Heme DVT prophylaxis Y NRestraint orders Y N
Nutritional needs addressed Y NFoley addressed Y N
Line removal addressed Y NFamily updated Y N
Signature: MD Pager Date Time
Teaching Physician DocumentationCritical 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 anytime 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 serviceslisted 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