Subjective
No Acute Events overnight. Pt denies CP, SOB, ABD pain, N/V/F/C.
Objective
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
Normal Physical Exam
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
Normal Neuro Exam
CN2-12 intact b/l. EOMI. 5/5 strength in UE and LE. Intact sensation b/l. No dysmetria, no dysdokinesia. Neg protanator drift, neg romberg. Gait nl.
Labs
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P
yo M/F with PMH * presents with
# FEN/GI: regular diet
# DVT PPX: heparin Subq
# Code Status: FULL CODE
# Dispo: Pending medical work-up
# Emergency Contact:
Brian Truong, p0503
Plan discussed with attending physician: Dr. *
Progress note Template
Reason for Continued Hospitalization:
Subjective:
Objective:
GEN: NAD, Laying Comfortably in bed
Meds:
Studies:
Labs:
A/P:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Plan discussed with Attending:
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
H&P Template
Date of Note:
Chief Complaint:
History of Present Illnesses:
Past Medical History:
Allergies:
Medications:
Past Surgical History:
Social History:
Review of Systems:
Family History:
Physical Examination:
GEN: NAD, Laying Comfortably in bed
Test Results:
Labs
Assessment and Plan:
[ ] Central line, PICC line, or dialysis catheter present and indicated
PLEASE SEE ATTENDING ADDENDUM
DISCUSSED WITH DOCTOR:
Used Interpreter - Name:
Used HCN - Interpreter ID #:
Interpretation language:
Progress note Template
Reason for Continued Hospitalization:
Subjective:
Objective:
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
GU/Pelvic/rectal: deferred
GU/Pelvic/rectal: deferred
Meds:
Studies:
Labs:
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
A/P:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Plan discussed with Attending:
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
H&P Template
Date of Note:
Chief Complaint:
History of Present Illnesses:
Past Medical History:
Allergies:
Medications:
Past Surgical History:
Social History:
Review of Systems:
Family History:
Physical Examination:
Vital Signs
Temp / HR / RR / BP / O2 Sat
/ / / /
24 hour I/O: /
GEN: NAD, Laying Comfortably in bed
HEENT: PERRLA, no jaundice
CV: rrr, no mrg, +S1, S2
PULM: CTAB, no crackles, wheezing, rales
ABD: soft, NTND, no rebound, no guarding
EXT: 2+ peripheral pulses. No edema b/l.
SKIN: no petechiae, no rash
NEURO: A&O x 3.
GU/Pelvic/rectal: deferred
GU/Pelvic/rectal: deferred
Test Results:
Labs
BMP
Na / K / Cl / HCO3 / BUN / Cr < Glu
/ / / / / <
Ca / Mg / Phos
/ /
CBC
WBC > Hgb / Hct < Plts
> / <
LFTs
Albumin / Tot Protein / D. Bili / T. Bili / AST / ALT < Alk Phos
/ / / / / <
Assessment and Plan:
yo M/F with PMH * presents with
# FEN/GI: regular diet
# DVT PPX: heparin Subq
# Code Status: FULL CODE
# Dispo: Pending medical work-up
# Emergency Contact:
[ ] Central line, PICC line, or dialysis catheter present and indicated
PLEASE SEE ATTENDING ADDENDUM
DISCUSSED WITH DOCTOR:
Used Interpreter - Name:
Used HCN - Interpreter ID #:
Interpretation language:
Discharge Summary
Date of Admission:
Date of Discharge:
Service:
Attending:
Resident:
Intern:
Discharge Diagnoses (no abbreviations; list all conditions from past medical history and that developed during hospitalization):
Procedures:
History of present illness:
Hospital Course:
Disposition:
Code Status:
Discharge Condition:
Pending Studies:
Discharge Activity:
Discharge Diet:
Discharge Medications:
Follow-up Instructions:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Discharge plan discussed with attending who concurs with plan.
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
Discharge Instructions
Discharge Service: Date of Admission:
Date of Discharge:
Service:
Attending:
Resident:
Intern:
Discharge Diagnoses (no abbreviations; list all conditions from past medical history and that developed during hospitalization):
Procedures:
History of present illness:
Hospital Course:
Disposition:
Code Status:
Discharge Condition:
Pending Studies:
Discharge Activity:
Discharge Diet:
Discharge Medications:
Follow-up Instructions:
[ ] Central line, PICC line, or dialysis catheter present and indicated
Discharge plan discussed with attending who concurs with plan.
Used Interpreter - name:
Used HCIN - Interpreter ID #:
Interpretation language:
Discharge Instructions
Discharge Attending:
Discharge Resident ([ ] licensed [ ] unlicensed):
Discharge Intern:
Date of Admission:
Date of Discharge:
Admission Diagnosis:
Primary Discharge Diagnosis:
Secondary Discharge Diagnoses:
[ ] MRSA-positive; patient notified and educated
Disposition: [ ] Home[ ] Home with Home Health[ ] Nursing Home [ ] Other:
Labs/Tests prior to discharge:
[ ] MRSA-negative chronic dialysis patient: perform MRSA nasal swab
Labs/Tests after discharge:
Follow-up in / Make referrals to (Doctor: please fill in consult/referral form):
1. Location: Date: Time: Bldg/Room#:
2. Location: Date: Time: Bldg/Room#:
3. Location: Date: Time: Bldg/Room#:
4. Location: Date: Time: Bldg/Room#:
Additional Instructions / Treatment at Home (e.g., return precautions, wound care, injections):
Medications (keep a list of ALL medications you take and bring it with you whenever you see a healthcare provider)
Your new medications are:
Continue your home medications:
Diet:[ ] Heart Healthy [ ] 2 gm sodium [ ] Diabetes [ ] Other:
Activities:[ ]As tolerated [ ] Restrictions: [ ] Return to Work in: ____ days
[ ] Discussed with Attending, who agrees with discharge plan
_____________________________________________________________________ _____________________________________________________________________
Patient Instructions BRING THIS FORM AND YOUR OLIVE VIEW IDENTIFICATION CARD (PLASTIC CARD) WITH YOU TO YOUR FOLLOW-UP CLINIC APPOINTMENT.
General Instructions If your symptoms recur or persist, return to the Emergency Room/Medical Walk-In; if life-threatening, call 911.
Additional Instructions:
For Patients Diagnosed with Heart Failure 1. Low salt, low cholesterol/fat diet, and restrict fluid intake as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor; schedule rest breaks as needed. 3. Weigh yourself daily on same scale in the morning; bring your weight record to your follow-up appointment. 4. If you experience any chest pain, increased bleeding or bruising, swelling in your legs or ankles, difficulties in breathing, or gain 2 or more pounds in one day or 5 or more pounds in one week, return to the hospital.
For Patients Diagnosed with a Heart Attack 1. Low salt, low cholesterol/fat diet, as directed by your doctor. 2. Gradually increase your activity, as directed by your doctor. 3. If you experience chest pain that does not go away, call 911.
For Patients Diagnosed with Stroke 1.Call 911 if you have a SUDDEN: numbness or weakness of the face, arm or leg, especially on one side of the body, confusion, trouble speaking, understanding, seeing, walking, or feeling dizzy, loss of balance or coordination, or a severe headache without cause. 2. Keep all doctor and test appointments. 3. Take all medications prescribed to you at discharge. 4. Be aware of risk factors for Stroke, such as: Cigarette smoking, alcohol abuse, being overweight, poor diet, not being active.
Outpatient Clinic Appointments 1. To make, change or cancel a clinic appointment, call (818) 364-3184. 2. Be prepared to tell the appointment clerk: medical record number, patient's name, birth date, telephone number and address. 3. Please arrive 15 minutes prior to your scheduled appointment time. 4. If you arrive later than 15 minutes after your scheduled appointment time, your appointment may be rescheduled or you may be referred to Emergency Room/Medical Walk-In if your condition warrants such. 5. If you are expecting to be late, you must call the clinic to find out if you can be accommodated.
Postoperative Discharge Instructions 1. Nausea and/or vomiting may occur in the immediate postoperative period. 2. If breathing difficulties, excessive bleeding, fever, or other disturbing problems should develop after leaving the hospital, return to the Emergency Room. 3. Do not drive a car or make any important decisions for the next 24 hours. 4. You must follow up with your primary doctor after discharge for instructions on the medications you took prior to surgery. 5. If you have been instructed to change your dressing, wash your hands before and after touching your wound/dressing.
Infection Prevention Strategies To prevent the spread of infections and multi-drug resistant organisms (MDROs) such as: 1. Methicillin Resistant Staphylcoccus Aureus (MRSA) 2. Vancomycin Resistant Enterococcus (VRE) 3. Extended Spectrum Beta Lactamase (ESBL) 4. Clostridium difficile (CDI) Wash hands frequently with soap and water for at least 15 seconds. Keep wounds covered. Regularly wash clothing, bedding and areas in your home that can become contaminated such as bathrooms and kitchen. Do not share personal items like towels, washcloths, bars of soap or razors.
Blood clot prevention: If you started on an anticoagulant (also called a ?blood thinner?) by mouth (for example, warfarin [COUMADIN]) or by injection (for example, enoxaparin [LOVENOX]), the anticoagulation handouts given to you by your Registered Nurse, summarize the education given to you in the hospital. For patients discharged on Warfarin [COUMANDIN], the hand out given & reviewed is '?What I Should Know about Warfarin?. It is important that you take your Warfarin as instructed, follow-up with your doctor and keep all blood test (PT/INR) monitoring appointments, follow your diet (consistent amount of foods that contain vitamin K) and avoid major dietary changes. As changes in diet or medication will affect your PT/INR level, inform your doctor of changes in your medications or over-the-counter medications, diet, or use of alcohol to avoid adverse drug reactions or interactions. Be aware of risks such as signs of bleeding or clotting; seek urgent/emergent care for any bleeding that is continuous or excessive. Wear a ?medic alert? bracelet.
RECEIPT FOR THIS PATIENT, IF CHILD OR WARD OF COURT Before permitting a child to leave the hospital, the responsible nurse will require the parent or legal guardian to sign below. When parent or guardian cannot be reached, the RESIDENT PHYSICIAN ON DUTY may authorize a relative or friend to sign the receipt when circumstances warrant. Receipt is not required for a minor deemed sufficiently responsible to look after himself. I have received ___________________________________ from the Los Angeles County Olive View-UCLA Medical Center, who is my __________________________ for whom I acknowledge full and complete responsibility.
Signature Printed Name Date
Address _______________________________________________________ Phone __________________________
Discharged with whom:
Discharge via:[ ] Ambulatory[ ] Stretcher[ ] Wheelchair
Discharge to:[ ] Ambulance[ ] County sedan[ ] Private car
Valuables/personal belongings returned?[ ] Yes[ ] No[ ] None
Supplies/equipment to send with patient:
Child Safety Info Given: [ ] Yes [ ] No [ ] N/A
Crisis Hotline Info: 1-877-727-4747
Smoking causes many health problems and can shorten your life. We advise you not to smoke. For free help with quitting, call 1-800-NO-BUTTS
(1-800-662-8887).
SIGNATURES
Clerk:
Printed Name Signature Date Time
Patient or responsible person: I hereby acknowledge the receipt of these instructions and understand them.
Printed Name Signature Date Time
Discharge Nurse/RN: I have verified that the Influenza/Pneumococcal vaccine(s) have been offered and administered to patient if criteria were met.
Printed Name Signature Date Time
