Hospital Progress note

Progress Note - [Location in hospital] (example is 3 west, 3 south, 4 north etc. including bed and room if mentioned) ID: - [Patient age], [Patient gender] - [Level of Intervention] (always include between A, B, C, D and wirte as "Level of Care" then the letter and between brackets discussed if not included then Write in bracket "assumed A but to be discussed") Reason for admission: - [Reason for admission] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Past Medical History: - [Past medical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Allergies - [Allergies] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Today: - [Current symptoms and complaints] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) OE: - [Vital signs] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Physical examination findings] (if I say insert hospital exam write " Good General State, no distress, no work for breathing Heart: normal S1, normal S2 with no murmurs No LL Edema Lungs: Normal Vesicular breathing, No crackles, No wheezing Abdomen: Soft, no tenderness, no Rigidity, no Rebound, negative Mcburney sign") Investigations: Labs: - [Laboratory results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise write "no new labs") Imaging: - [Imaging results] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, write "no new imaging") - [Other diagnostic tests] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) Treatment Plan: [1. Issue, problem, or request 1 (issue, request or condition name only)] - [Impression, likely diagnosis for Issue 1 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Differential diagnosis for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Investigations planned for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Treatment planned for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Relevant referrals for Issue 1] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) [2. Issue, problem, or request 2 (issue, request or condition name only)] - [Impression, likely diagnosis for Issue 2 (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Differential diagnosis for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Investigations planned for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Treatment planned for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Relevant referrals for Issue 2] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) [3. Issue, problem, or request 3, 4, 5 etc. (issue, request or condition name only)] - [Impression, likely diagnosis for Issue 3, 4, 5 etc. (condition name only)] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Differential diagnosis for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Investigations planned for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Treatment planned for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Relevant referrals for Issue 3, 4, 5 etc.] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely) - [Current treatment plan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Medications administered] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) - [Interventions performed] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.) [4. Discharge Planning & Other:] (always include giving it the next number after all medical issues listed above) - [Expected date of discharge] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank, include it as the before last issue/problem include it as before last issue/problem give it the next number in issues) - [Prophylactic anti-coagulation] : (Has to be included in note, can insert from hospital medication above if heparin, fragmin, lovenox, eliquis/apixaban or other anticoagulation) - [Foley cathéter:] (Has to be included in note either yes or no and highlight if not mentioned in transcript) - [GFR/Kidney function: ] (use GFR or creatinine mention in the labs section) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note.)