General Note Tips

Chief Complaint: Identify what the patient symptom was on arrival to the hospital

History of Present Illness: Identify the patient's age, past medical history, and all information that the patient is able to supply on admission to the hospital about what brought them into the ED. This should include any symptoms, onset,  interventions prior to arrival, and anything of relevance that the patient can tell you. Often providers will include pertinent findings from the ED work up in this section. If the patient is not able to participate in the HPI section, the reason why should be listed. 

Hospital Course: Start with today's date and then concise description of pertinent events in the last 24 hours 

Impression List: Any diagnosis that is relevant to the patient's stay. This should be reviewed and updated daily with any diagnosis that is no longer treated being either removed or tagged as resolved. For example, Acute Hypoxic Respiratory Failure, resolved. 

Plan: For patients that the ICU team is the attending on, this will be a systems based format. Providers will vary somewhat, but generally after the system is listed we include the problem, data supporting the problem or ruling out other potential problems on top. Underneath will be dashes followed by actual actions that are treating the above problem. 

                                ***     Example   ***

Cardiac: Heart failure with Reduced EF. Echo 2/23/07 with normal RV, estimated EF 25%

- Lisinopril 20 mg daily

- Metoprolol 25 mg BID 

Review of Systems:  This section includes any information the patient tells you on the day you are writing your note. For the initial HPI or Consult note, a 12 point review of systems will be auto-populated for you. For subsequent notes, a 3 point ROS is adequate. 

Physical Assessment: This section will include your physical exam findings.